CLINICAL CARE OF THE HIP, THIGH, AND KNEE

Question 1

What Dx/ Tx
Occurs when the femoral head is displaced from the acetabulum
Clinical symptoms
(1) Severe pain
(2) Fixed extremity
(3) Numbness/tingling common
Physical exam
(1) Posterior dislocation: Affected limb short, hip is fixed in adducted and internally rotated
position
(2) Anterior dislocations: hip held in abduction and external rotation
(3) Severe tenderness
(4) Decreased ROM
(5) Assess neurovascular status

Answer 1

Hip Dislocation.
Treatment
(1) MEDEVAC
(2) Reduction
–(a) Performed ASAP to reduce risk of osteonecrosis
——1) Disrupts blood supply to the femoral head in about 10% of cases
–(b) Reassess neurovascular status
(3) SIQ until eval by ortho

Question 2

Diagnostic tests hip dislocation
(1) Radiographs of ____, _____ and _____
(2) CT scan to eval for ______

Answer 2

1) Hip knee and pelvis
2) fracture pattern

Question 3

What Dx/Tx
Mostly caused by high energy trauma
(1) Associated with many severe, life threatening injuries
(2) Pulmonary
(3) Vascular complications
(4) Intra-abdominal injuries
(5) Head injuries
Clinical symptoms
(1) Severe pain in thigh
(2) Unable to bear weight
Physical exam
(1) Obvious deformity, edema, possible open injury
(2) Severe tenderness over fracture
(3) Evaluate neurovascular status
–(a) Femoral, peroneal, posterior tibial nerves
–(b) Femoral, popliteal, posterior tibialis, dorsalis pedis pulses

Answer 3

Femur shaft Fx
Treatment
(1) Immediate splinting and traction
(2) MEDEVAC
(3) Surgical management required
(4) If open wound, apply dressing

Question 4

What Dx/Tx
Often misdiagnosed or completely missed
(1) Occurs in patients who undergo repetitive impact
(2) Military recruits, athletes, runners
Clinical symptoms
(1) Vague pain in anterior groin or thigh
–(a) Exacerbated by activity and weight bearing
–(b) Relieved with rest
(2) Story of increasing activity prior to pain onset
–(a) Increasing mileage as a runner, for instance
Physical Exam
(1) Antalgic gait
(2) Tenderness to proximal thigh/groin
(3) Limited ROM
–(a) Particularly internal rotation
(4) Pain to groin or thigh with straight leg raise

Answer 4

Stress Fracture of the Femoral Neck
Treatment
(1) Analgesics
(2) Ortho evaluation
(3) Activity modification
–(a) Crutches
–(b) Non weight bearing

Question 5

Dx/Tx
Clinical Symptoms
(1) Pain in groin area with attempted weight bearing
(2) Sensation of “coming apart” at the hip with bearing weight
(3) High energy fractures
–(a) Other distracting injuries
—-1) Head, chest, abdomen
–(b) Shock, multisystem trauma
c. Physical exam
(1) Presentation depends on severity
(a) Antalgic gait vs gross deformities
(b) Edema/echymmosis
(2) Tender to palpation
(3) Limited ROM
(4) Assess neurovascular status
–a) Peripheral nerve injuries common
–(b) Complete vascular exam

Answer 5

Fracture of the Pelvis
Treatment
(1) MEDEVAC
(2) Hemodynamic resuscitation
(3) Activity modification
–(a) No weight bearing
(4) Pain management
–(a) Narcotics
(5) Pelvic binder

Question 6

Pelvis Fx diagnostic testing considerations

Answer 6

(1) Radiographs
–(a) Pelvis, hip, head, cervical, chest
(2) Urinalysis
–(a) Hematuria common
(3) Hematocrit
–(a) Evaluating blood loss

Question 7

What Dx/TX
Vigorous muscle contraction while muscle is on stretch causes the injury
(1) Results from acute or overuse injury to ether the Iliopsoas, Sartorius, Rectus Femoris.
Clinical symptoms
(1) Pain over inured muscle
–(a) Exacerbated by activity
Physical exam
(1) Mild ecchymosis or edema possibly
(2) Tenderness to affected muscle group
–(a) Groin, inner thigh, ASIS/anterior thigh
(3) Increased pain while attempting to range the hip
(4) Strength limited by pain (4/5)
(5) Special Test
–(a) Thomas test for hip flexor tightness

Answer 7

Hip Strain
Treatment
(1) Light duty/activity modification
(2) NSAIDs
(3) Pain free hip stretching and strengthening
(4) Run-walk program
–(a) Progressive return to full duty
(5) Send to ortho if failed conservative management

Question 8

Diagnostics Hip strain
(1) Plain films of _____ and ____ considered
(2) MRI reserved for _______

Answer 8

1) pelvis and hip
2) chronic pain/unclear diagnosis

Question 9

Thigh Strain (hamstring muscles/quadriceps)
The _________ are injured more often

Answer 9

posterior thigh muscles (hamstring muscles)

Question 10

What Dx
Strain/tear typically occurs at the musculotendinous junction
Clinical Symptoms
(a) A patient with this typically reports a sudden onset of posterior or thigh pain that occurred while running, water skiing, or some other rapid movement
(b) A “pop” may have been perceived at the onset of pain
Physical Exam
(1) Ecchymosis is common
(2) Tenderness to palpation to affected muscle group
(3) Pain while attempting to flex at the knee

Answer 10

hamstring strain
-Thigh Strain

Question 11

What Dx
Strain/tear typically occurs at the musculotendinous junction
Clinical Symptoms
(a) injury associated with direct blows during contact sports that results in a contusion
(b) A “pop” may have been perceived at the onset of pain
Physical Exam
(1) Ecchymosis is common
(2) Tenderness to palpation to affected muscle group
(3) Pain while attempting to extend at the knee

Answer 11

Quadriceps strain
(Thigh Strain)

Question 12

Treatment Thigh strain
1) Initial treatment includes prevention of further swelling and hemorrhage by having the patient _____________________________
(2) As time passes, the patient should begin a program of rehabilitation with pain free stretching and strengthening of the injured muscle
(3) NSAIDs
(4) The degree of rehabilitation necessary depends on the patient’s general activity level and the severity of the injury

Answer 12

1) rest and elevate the limb while applying ice and compressive wraps as needed

Question 13

What Dx/Tx
Clinical Symptoms
(1) Patients usually have pain and tenderness over the greater trochanter (ie: lateral hip pain)
(2) The pain may radiate distally to the knee or ankle (but not onto the foot) or proximally into the buttock
(3) Pain worse when going from sit to stand
(4) May decrease after warming up but return after 30 to 1 hours of walking
(5) Unable to lie on affected side
Physical Exam
(1) No deformities on exam
(2) Point tenderness over the lateral greater trochanter is essential finding
(3) Patients report increased discomfort with hip adduction or adduction with internal rotation
(4) Resisted hip abduction also causes pain
(5) Trendelenburg test
(6) Faber

Answer 13

Trochanteric Bursitis.
Treatment
(1) NSAIDS
(2) Light Duty- Activity modification
(3) Hip strengthening(focus on abduction) and stretching
(4) Refer to ortho if conservative management failed

Question 14

Diagnostic Tests
(1) Hip radiographs usually (ARE/NOT) necessary
–(a) to rule out bony abnormalities and intraarticular hip pathology
–(b) Bone scans and MRI are (RARELY/OFTEN) needed to make the diagnosis

Answer 14

1) Not
b) Rarely

Question 15

The _______ ligament is a primary stabilizer of the knee
(1) Limits anterior translation of the tibia on the femur
(2) A tear of this ligament results from a rotational (twisting) or hyperextension force

Answer 15

anterior cruciate ligament (ACL)

Question 16

Dx/Tx
Clinical symptoms
(1) Pt’s with this tear usually report sudden pain and giving way of the knee from a twisting or hyperextension-type injury
(2) 1/3 report an audible “pop” as the ligament tears
(3) Pt’s who sustain this during athletic activity usually is unable to continue
participating because of pain and/or instability
c. Physical Exam
(1) Moderate to severe effusion
(2) Possibly hemarthrosis (bleeding in the joint)
(3) Palpation
–(a) Generalized knee tenderness
(4) ROM
–(a) Limited by pain and effusion
–(b) Locking/popping sensation
(5) Muscle Test
–(a) Limited by pain
(6) Special Tests:
–(a) Anterior drawer and Lachman. Negative in many patients who have this tear

Answer 16

ACL Tear
Treatment
(1) RICE
(2) Light Duty to include running or cutting activities
(3) Orthopedic Consult * Required*
(4) Physical Therapy Consult
(5) A knee immobilizer or range-of-motion brace may be used for comfort when necessary until acute pain subsides

Question 17

PCL Vs ACL tear
(1) Strongest ligament in the knee
(2) Prevents posterior translation of the tibia on the femur
(3) Injury caused by stretch or complete rupture of the ligament
(4) Less common than other ligamentous/meniscal injury

Answer 17

PCL Tear

Question 18

What are the four injury patterns suggest the possibility of a PCL injury?

Answer 18

(a) Dashboard injury-a posteriorly directed force to the anterior knee with the knee in flexion, as in a motor vehicle accident
(b) A pure hyperflexion injury to the knee
(c) A hyperextension injury to the knee typically, the ACL ruptures first, and then with sufficient force, injury to the PCL follows
(d) Fall onto a flexed knee with the foot in plantar flexion

Question 19

What Dx / Tx
One of these four MOI
-Dashboard injury
-A pure hyperflexion injury to the knee
-hyperextension injury
-Fall onto a flexed knee with the foot in plantar flexion
Physical Exam
(1) Visual
–(a) Moderate to severe effusion with echhymosis
—-1) Particularly with high energy injuries
–(b) Effusion and muscle guarding may mask increased translation
(2) Palpation = General knee tenderness with focus to posterior knee
(3) ROM = Limited by pain and effusion
(4) Muscle Test = Limited by pain
(5) Neurovascular = Unremarkable
(6) Special Test
–(a) Positive Posterior Drawer
–(b) Positive Sag test

Answer 19

PCL Tear
Treatment
(a) RICE
(b) NSAIDs/Tylenol
(c) Light Duty to include running or cutting activities
(d) Orthopedic Consult
(e) Physical Therapy Consult

Question 20

Diagnostic tests PCL Tear
(a) ___ can be useful in confirming PCL tears, as well as any concomitant injuries to
ligaments, menisci, and articular cartilage
(b) _______ are needed to rule out dislocations or other bony pathology

Answer 20

a) MRI
b) Radiographs

Question 21

Collateral ligaments
(1) Stability of the knee joint is largely dependent on its ligaments and ________ muscles
(2) The medial and lateral collateral ligaments are outside the joint and stabilize the knee against ____ and ______ stresses

Answer 21

1) periarticular
2) Valgus and varus

Question 22

MCL vs LCL
(1) ____ tear results from valgus force
(2) ____ from varus force

Answer 22

1. MCL
2. LCL

Question 23

What Dx / tx
Physical Exam
(1) Tear results from ether Valgus or Varus force
(2) Visual
–(a) Within 24 to 48 hours, localized ecchymosis and a small effusion develop
(3) Palpation = Tenderness to medial or lateral knee
(4) ROM = Limited by pain or effusion
(5) Muscle Test = Limited by pain
(6) Neurovascular = Typically unremarkable
(7) Special Tests
–(a) Valgus/varus stress testing

Answer 23

Collateral ligament Tear (MCL or LCL)
Conservative treatment
(a) Physical therapy
(b) NSAIDS
(c) RICE
(d) Hinged brace
(e) Crutches, weight bearing as tolerated (WBAT)
(f) Ortho consult if conservative management fails

Question 24

MCL Tear
(a) Usually non operative and heal within __-__ weeks
(b) Contact __

Answer 24

a) 4-6
b) MO

Question 25

LCL Tear
(a) May be treated non surgically depending on grade
(b) Grade ___ require surgical management
(c) ____ consult

Answer 25

b) III
c) Ortho

Question 26

_______ lie between the skin and bony prominences or between tendons, ligaments, and bone
(1) They are lined by synovial tissue, which produces a small amount of fluid to decrease friction between adjacent structures

Answer 26

Bursae

Question 27

_________ causes thickening of the Bursae and subsequent excessive fluid formation, thereby leading to localized swelling and pain

Answer 27

Chronic pressure or friction (overuse)

Question 28

The ______ bursa on the anterior aspect of the knee is superficial and lies between the skin and the bony patella

Answer 28

prepatellar bursa (Housemaid’s knee)

Question 29

The _______ bursa lies under the insertion site of the sartorius, gracilis, and semitendinosus muscles on the medial flare of the tibia just below the tibial plateau

Answer 29

pes anserine

Question 30

What issue / tx
-Chronic pressure or friction (overuse) causes thickening of this synovial lining and subsequent excessive fluid formation, thereby leading to localized swelling and pain
-Pain with activity and direct pressure
-The pain often is more severe after the patient has been sedentary for some time, and patients will notice a limp when first arising from a chair
Physical Exam
(1) Visual = dome shaped swelling over the anterior aspect of the knee
(2) Palpation = tenderness to fluid filled dome shape over patella
(3) ROM
–(a) May be limited by pain and pressure
–(b) Muscle Test = May be limited by pain
(c) Neurovascular = Normal
(d) Special Test = None

Answer 30

Prepatellar bursitis
Treatment
(1) RICE
(2) NSAIDS
(3) Light duty- activity modification
(4) Pain free LE stretching and strengthening exercises
(5) Antibiotic treatment for septic bursitis

Question 31

What issue / tx
-Chronic pressure or friction (overuse) causes thickening of this synovial lining and subsequent excessive fluid formation, thereby leading to localized swelling and pain
-Pain with activity and direct pressure
-The pain often is more severe after the patient has been sedentary for some time, and patients will notice a limp when first arising from a chair
Physical Exam
(1) Visual = mild swelling to medial aspect of the knee
(2) Palpation = Tenderness focal medial flare of the tibia just below the tibial plateau
(3) ROM
–(a) May be limited by pain and pressure
–(b) Muscle Test = May be limited by pain
(c) Neurovascular = Normal
(d) Special Test = None

Answer 31

pes anserine bursitis
Treatment
(1) RICE
(2) NSAIDS
(3) Light duty- activity modification
(4) Pain free LE stretching and strengthening exercises
(5) Antibiotic treatment for septic bursitis

Question 32

Bursitis
Increased pain, warmth and erythemtous changes may indicate _______

Answer 32

septic bursitis

Question 33

____ is a dense, fibrous band of tissue that originates from the anterior superior iliac spine region, extends down the lateral portion of the thigh and inserts on the lateral tibia at the Gerdy tubercle

Answer 33

Iliotibial band

Question 34

IT Band Syndrome
Very common
(1) up to 25% of physically active people
(2) This syndrome (HAS NOT/HAS) been reported in people that do not exercise
(3) Mostly seen in _____ and cyclists
(4) ___% of knee pain in cyclists is secondary to IT Band syndrome
(5) Up to __% of runners affected

Answer 34

(2) HAS NOT
(3) runners
(4) 24%
(5) 12%

Question 35

What Dx / Tx
Very common in Runners and Cyclists
Clinical Symptoms
(1) Pain focal to the anterior lateral aspect of the knee that worsens with activity
–(a) Worse with downhill running, mostly during heel strike
(2) Discomfort or complete resolution at rest
Physical Exam
(1) Visual
–(a) May note deviations from normal
—-1) Genu varum (bow legs)
—-2) Pes planus
—-3) Tibial internal rotation
(2) Palpation
–(a) Tenderness to direct palpation over/near the lateral femoral condyle
–(b) Tenderness may extend above or below the lateral femoral condyle
(3) ROM = Unremarkable
(4) Muscle Test = Unremarkable
(5) Neurovascular = Unremarkable
(6) Special Test = Positive Obers
——Positive pain when jumping on flexed knee

Answer 35

ITBS
Treatment
(1) NSAIDS
(2) Foam rolling
(3) Light Duty
(4) Modifications to training regimen
–(a) Proper running time/distance progression
–(b) Hamstring and ITB stretching
–(c) Hip abductor strengthening

Question 36

When are diagnostic studies ordered for ITBS

Answer 36

1) Obtained in patients with persistent symptoms despite treatment
2) MRI if the diagnosis remains unclear

Question 37

What Dx/Tx
Clinical Symptoms
(1) Mechanical symptoms in the knee such as locking, catching, and popping can then develop; patients usually experience pain with twisting or squatting
Physical Exam
(1) Visual =Traumatic meniscal injury results in moderate to severe effusion
(2) Palpation = Tenderness over the medial or lateral joint lines
(3) ROM = Usually normal but may be seriously disrupted
—(a) (Bucket handle tears), leading to a “locked knee“ - this requires more urgent orthopedic evaluation
—(b) Knee motion may be limited secondary to pain or an effusion
—(c) Knee may feel as though it is “catching” thru range of motion
(4) Muscle Test = May be limited by pain
(5) Neurovascular = Unremarkable unless other injury is present
(6) Special Test =Positive McMurray

Answer 37

Meniscal Tear
Treatment
(1) Locked knee (i.e.: bucket handle tear) should promptly be treated with urgent referral to ortho
(2) If absence of mechanical locking then treatments should start with RICE
(3) NSAIDS
(4) ROM and pain free strengthening exercises
(a) Consult to orthopedics
(b) Patient with traumatic effusion and mechanical symptoms need urgent orthopedic evaluation

Question 38

What Dx / Tx
-Associated with jumping sports
-Also seen in patients who increase physical training too quickly
Clinical Symptoms
(1) Anterior knee pain is the hallmark; patients often point to a tender spot where symptoms concentrate
(2) Location depends on tendon insertion site involved
–(a) Superior pole of the patella- quadriceps tendon insertion
–(b) Inferior pole of patella- patellar tendon originates
(3) Pain is exacerbated by exercise
(4) Exacerbated by prolonged sitting, squatting, or kneeling in some cases
(5) Climbing or descending stairs, running, and, of course, jumping often increase the pain
Physical Exam
(1) Visual
–(a) Usually unremarkable
–(b) Mild infrapatellar bursa swelling
(2) Palpation
–(a) Tenderness at tendon insertion/origination sites as discussed
–(b) Crepitus
(3) ROM = Knee motion normal but pain with extension
(4) Muscle Test = Unremarkable
(5) Neurovascular = Unremarkable
(6) Special Test = None

Answer 38

Quadriceps / Patellar Tendinitis “Jumpers knee”
Treatment
(1) NSAIDS
(2) Ice
(3) Light duty
(4) Pain free quadriceps and hamstring stretching and strengthening
(5) Patellar tendon strap- Chopats for comfort

Question 39

What issue /tx
-Overuse disorder characterized by pain around the patella aggravated by activities that load the patellofemoral joint
-Most common cause of knee pain in primary care setting
Clinical Symptoms
–(a) Around 20% among adolescents
–(b) Most common in third decade of life
(1) Diffuse aching anterior knee pain
(2) Exacerbated by prolonged sitting (theater sign), climbing stairs, jumping, or squatting
(3) Usually no preexisting trauma
(4) Some patients report a sense of instability or a retropatellar catching or grinding sensation
(5) Usually no history of swelling is reported
Physical Exam
(1) Recommend evaluating for gross misalignments and note deviations from normal:
–(a) Femoral anteversion
–(b) Genu valgum
–(c) Foot over pronation
–(d) Patellar tracking
–(e) VMO definition
(2) Palpation
–(a) Tenderness noted to medial and/or lateral subpatellar borders
–(b) Crepitus maybe noted with patellar mobility (nonspecific finding)
(3) ROM
–(a) Typically grossly normal
–(b) Hamstring flexibility should be tested
(4) Muscle Test = Unremarkable
(5) Muscle Test = Normal
(6) Neurovascular = Unremarkable
(7) Special Test
–(a) Evaluate for patellar apprehension patellar instability
–(b) Should only be able to mover patella one quadrant medially and two quadrants laterally
–(c) Hamstring flexibility via Popliteal angle

Answer 39

Patellofemoral Pain
Treatment
(1) NSAIDS
(2) Ice
(3) Light Duty-Active Rest
(4) Quadriceps and hamstring flexibility and strengthening
(5) Weight loss is recommended when a patient is obese
(6) Support biomechanical limitations
–(a) McConnel taping
–(b) Patellar tracking brace
–(c) Motion control shoe/Inserts

Question 40

Studies among military recruits identified what several risk factors for Patellofemoral Pain?

Answer 40

(a) Fitness level upon entry to service
(b) Prior exercise behavior
(c) BMI over 25
(d) Training load

Question 41

What Dx / Tx
Clinical Symptoms
(1) Swelling/fullness in the popliteal fossa
(2) Posterior knee pain
(3) Knee stiffness
(4) Small cysts may be asymptomatic
(5) Larger cysts can dissect down the posterior calf and/or rupture, resulting in severe calf pain and decreased motion at the ankle
Physical Exam
(1) Visual = Edema to the popliteal fossa
(2) Palpation
–(a) Palpate the area to determine the size, consistency, and amount of tenderness
(3) ROM
–(a) Flexion may be limited by pain and excessive joint fluid
(4) Muscle test = Flexion may be limited by pain
(5) Neurovascular = Unremarkable
(6) Special Test = None

Answer 41

Popliteal Cyst, Also called Bakers cyst
Treatment
(1) NSAIDS and or analgesics
(2) Ice
(3) Light duty-activity modification
–(a) Return to activities pain free
–(b) Orthopedic consultation if symptomatic

Question 42

When should you refer Popliteal Cyst

Answer 42

-Constitutional symptoms
-If DVT is suspected

Question 43

What Dx / Tx
Common cause of anterior knee pain in younger population
-Typically seen between ages of 14-18, possibly later in males
Clinical Symptoms
(1) Anterior knee pain that increases gradually over time
(2) Exacerbated by direct trauma, kneeling, running ,jumping and other activity
(a) Relieved by rest
(3) Typically asymmetric, occasionally bilateral
Physical Exam
(1) Visual = Normal to slight swelling/bony prominence of tibial tubercle
(2) Palpation = Tenderness to tibial tubercle
(3) ROM = Typically normal
(4) Muscle test = Pain with resisted extension of knee
(5) Neurovascular = Unremarkable
(6) Special Test = None

Answer 43

Osgood Schlatter Disease
Treatment
(1) Usually benign and self-limited
–(a) Resolves when the growth plate reaches skeletal maturity (i.e.: stop growing)
(2) NSAIDS
(3) Protective pad over knee
(4) Duty modification
–(a) Avoid complete rest
(5) Home Exercise Program
–(a) May consider physical therapy

Question 44

When should you refer Popliteal Cyst

Answer 44

-Constitutional symptoms
-If DVT is suspected