Approach to Knee Pain Flashcards
What direction does Fibular head move with foot pronation?
Anteriorly
What direction does Fibular head move with foot supination?
Posteriorly
What is crepitus
Palpatory sensation of “grinding” during range of motion.
What is Osgood-Schlatter Disease/Syndrome?
Commonly occurs with increase activities such as sports—running, cutting, jumping—which causes microtrauma to the patellar ligament insertion onto the tibial tuberosity.
Most common between ages of 8-15
How to test for Osgood-Schlatter Disease/Syndrome?
Point tenderness over the tibial tubercle
All other ligament and structural testing is negative
radiography unnecessary
Signs of knee Osteoarthritis
Boney enlargement or deformity at the joint margins, genu varum deformity, and stiffness lasting ≤ 30 minutes are typical findings in OA
Crepitus is common.
Risks of knee Osteoarthritis
Increasing age
Trauma
Obesity
Anatomic factors (Varus/valgus deformities)
What is Housemaids Knee?
Bursitis of the knee
Chronic microtrauma from repetitive activity or pressure
Presents with local swelling, tenderness, erythema & warmth
Signs of Knee Bursitis?
Redness (erythema) and swelling at the site of the bursa
Tenderness and warmth
Remaining exam: Ligaments intact
What is Patellofemoral Pain Syndrome\Chondromalacia Patella?
Pain on or around the patella Insidious onset
Diffuse, aching, anterior knee pain
Can be unilateral or bilateral
Aggravated by climbing stairs, ascending hills, squatting or sitting for prolonged period of time (“theater sign”)
May have associated crepitus (grinding) with above activities
How to test Patellofemoral Pain Syndrome?
Crepitus under the patella w/AROM & PROM
+ Patellar grind test
What is Iliotibial Band Syndrome
Pain over the lateral aspect of the knee (above the joint line)
How to test Iliotibial Band Syndrome ?
Appear symmetric No warmth or erythema Pain with palpation over the lateral femoral condyle Normal ligamentous testing Positive OBER’s test on effected side. Assess Fibular head for dysfunction
Patellar Subluxation (Dislocation) Test?
Apprehension test. They don’t want you to touch it
ACL Tear test?
Anterior Drawer test / lachman test
What causes ACL tear
Hyperextension or sudden rotation (valgus deformation)
Symptoms of ACL tear?
Sudden onset severe knee pain with large effusion developing within 2 hours typically from hemarthrosis
Patient can report “popping sensation” or knee instability (giving out)
Can have associated injuries to meniscus, joint capsule, articular cartilage, subchondral bone (bone bruise), and other ligaments
Meniscal Injuries symptoms?
Slow onset knee pain with swelling or effusion developing over the next 24 hours
Degree of pain related to severity of meniscal tear
Patients with untreated meniscal tears for weeks can report “locking” or “catching” of knee during extension
Others can report “popping” or “giving out” sensation or vague sense knee is not moving properly
Unhappy Triad is what?
ACL, MCL, and MEdial meniscus
How to test for meniscus?
McMurray Test and Apley Grind
ROM of Knee Flexion?
145° - 150
ROM of Knee extension?
0
Patellar Reflex Documentation?
4+/4: Very brisk, hyperactive, with clonus
(rhythmic
oscillation between flexion and extension)
3+/4: Brisker than average, possibly but not
necessarily indicative of disease
2+/4: Average, normal
1+/4: Somewhat diminished, low normal
0/4: No response
Patellar Reflex Nerve Root?
L4
Popliteal Pulse Documentation?
+3 /: 3 Bounding
+2 /3 : Average intensity, expected, normal
+1 /3 : Diminished, barely palpable
0 /3 : Absent, not palpable
Edema of foot documentation?
0 : Abse nt 1+: Barely detectable, slight pitting (2m m); disappears rapidly 2+: Slight indentation (4 mm); 10 - 15 sec 3+: Deeper indentation (6 mm); >1 min 4+: Very marked indentation (8mm); 2 - 5 min
How to do Valgus test?
Patient supine with the knee flexed to 30°. Physician
supports the lower leg with one and other hand placed on
the lateral aspect of the patient’s knee. Apply a medial
force to the proximal tibia while abducting the lower leg.
This test is done at 30° flexion and neutral (0°).
Valgus test indications?
(+) Test: Increased laxity, soft or absent endpoint, pain
Indication: Medial collateral ligament (MCL) disruption
If positive at 0° with knee fully extended, indicates more
serious injury, possibly joint capsule
How to do Varus test?
Patient supine with the knee flexed to 30°. Physician
supports the lower leg with one and other hand placed on
the medial aspect of the patient’s knee. Apply a lateral
force to the proximal tibia while adducting the lower leg.
This test is done at 30° flexion and neutral (0°).
Varus test indications?
(+) Test: Increased laxity, soft or absent endpoint, pain
Indication: Lateral collateral ligament (LCL) disruption
How to do Anterior Drawer Test?
Patient supine with knee flexed to 90°. Examiner sits on the
patient’s foot and grasps the proximal tibia with both hands,
pulling the tibia anteriorly.
Anterior Drawer Test indications?
(+) Test: Excessive translation
Indication: ACL insufficiency (injury/tear)
Lachman’s
How to do Lachman’s Test?
Patient supine. Examiner places cephalad hand on the
distal thigh, superior to patella. Caudad hand grasps the
proximal tibia. Flexing the knee to 10-30°, the examiner
uses his caudad hand to pull the tibia anteriorly while the
cephalad hand stabilizes the thigh.
Lachman Test indications?
More sensitive test
(+) Test: Increased laxity, soft or absent end point
Indication: ACL insufficiency (injury/tear)
How to do Posterior Drawer Test?
Patient supine with knee flexed to 90°. Examiner sits on the
patient’s foot and grasps the proximal tibia with both
hands, translating the tibia posteriorly.
Indications of A Posterior Drawer Test?
(+) Test: Excessive translation
Indication: PCL insufficiency, posterior capsular injury or
disruption (injury/tear)
How to do McMurrays Test?
Patient is supine, with hip and knee flexed. Examiner uses
caudad hand to control the ankle and cephalad hand
placed on distal femur.
o Lateral Meniscus = Examiner rotates the tibia into
internal rotation and applies a varus stress, then
continues the leg into extension
o Medial Meniscus = Examiner rotates the tibia into
external rotation and applies a valgus stress, then
continues the leg into extension
Indications of McMurrays Test?
(+) Test: Pain or a palpable click during extension
Indication: Possible medial or lateral meniscus tear
How to do Apley’s Grind Test- Compression test
Patient prone with knee flexed to 90°. Examiner uses
downward force on the foot to provide a compressive force
on the meniscus, while rotating the foot internally and
externally
Indications of Apley’s Grind Test- Compression test?
(+) Test: Pain with rotation and/or compression
Indication: Possible meniscal injury, collateral ligament
injury, or both
How to do Apley’s Grind Test- Distraction test
Patient in same position as for the compression. Examiner
stabilizes the thigh, then applies upward traction to the leg
while rotating it
Indications of Apley’s Grind Test- Distraction test
(+) Test: Pain with distraction and rotation o
Increased ligamentous strain o Indication:
Possible collateral ligament damage
(+) Test: Relief of pain with distraction and
rotation o Reduced meniscal pressure
Indication: Possible meniscus injury
How to do Patella-Femoral Grinding Test
Compress patella caudally into trochlear groove and
instruct patient to tighten quadriceps against resistance
Indications of Patella-Femoral Grinding Test
(+) Test: Crepitus or pain
Indication: roughness of articulating surfaces (ie:
chondromalacia)
How to do Bounce Home Test
Patient is supine, the patient’s heel is in the caudad
hand of the examiner. With the knee completely
flexed, the knee is passively allowed to extend. The
knee should extend completely, or ‘bounce home’
into extension with a sharp end point.
Indications of a Bounce Home Test
If extension is
not complete or has a rubbery end fell, there is likely
a torn meniscus and/or effusion.
how to do a Bulge sign?
With knee extended, place the left hand above the
knee and apply pressure on the suprapatellar pouch,
‘milking’ the fluid downward.
Apply pressure on the medial aspect to force fluid
laterally.
Tap the knee just behind the lateral margin with the
opposite hand
Indications of a Bulge sign?
A fluid wave toward the lateral aspect OR a bulge on
the medial side is positive for effusion
If you hear a pop it is a sprain or strain?
Sprain
How to do IT band Strech?
Pt prone
Physician on contralateral side,
Caudad hand holding ankle,
Cephalad hand on lateral mid-thigh over IT Band
Patient’s leg rotated lateral while simultaneously compressing the IT band and pulling posteriormedially into restrictive barrier
How to do IR/ER tibia SD?
Seated, use foot to do MET with.
How to treat Fibular head SD?
Use foot in supine/ pronation to act as long lever.
