Evidence Based Management of the Knee Flashcards
the lateral femoral condyle extends more …
posteriorly
the medial femoral condyle extends more…
distally
which meniscus is more O shaped?
the lateral meniscus
which meniscus is more C shaped?
the medial meniscus
does the lateral meniscus cover more of the lateral femoral condyle or does the medial meniscus cover more of the medial femoral condyle?
the lateral meniscus covers more of the lateral femoral condyle more than the medial meniscus covers of the medial femoral condyle
which meniscus has an attachment to the popliteus?
the lateral meniscus
why is the lateral meniscus less injured?
bc it moves posteriorly when you flex the knee to get out of the way
the menisci are ____ M/L and _____ A/P
concave, convex
what is the plica?
a fold in the knee capsule
the cruciate ligaments are _____ and _____
intraarticular, extracapsular???
t/f: the medial condyle curve into the transverse plane allowing some abd/add at the the knee some
true
what may popping/locking at the knee indicate?
meniscus injury
what may instability at the knee indicate?
ligament injury
what may tingling at the knee indicate?
nerve injury
what may bruising at the knee indicate?
ligament injury
contusion/blow to the knee
where would the meniscus bleed?
in the outer red red or red white zones
if there is immediate swelling would this indicate a ligament or meniscus injury?
ligament injury
if there is delayed swelling would this indicate a ligament or meniscus injury?
meniscus injury
what is the Hx of present illness for the meniscus?
pain with flexion, locking, crepitus, and pain with torsion
what is the hx of present illness with OA?
pain in the am, better after, then worse again by night after weight bearing all day
stiffness in am and after immobility
what is the hx of present illness with PFPS?
anterior knee pain
pain w/sitting (movie-goers sign), stairs, kneeling, and often crepitus
what is the hx of present illness for an ACL injury?
pain/injury w/torsion, feeling of instability, edema upon injury, often pop at the time of injury
what is a common proximal influence for knee pain?
glut med weakness
what is a common distal influence for knee pain?
pes planus
if there is a valgus force at the knee, what injury may result?
ACL, MCL
if there is a varus force at the knee, what injury may result?
PCL, LCL
what is genu varum?
lateral angulation of the knees (bow legged)
what is genu valgus?
medial angulation of the knees (knock knees)
what is genu recurvatum?
hyperextension of the knees
what conditions may result in genu recurvatum?
coxa valga (long leg) ispilaterally, coxa vara (short leg) contralaterally, tight gastroc, LACK OF DF (equina varus)
what is patella alta?
high located patella
what is patella baja?
low located patella
what may result in patella baja?
tight patellar tendon
what can we do for a tight patellar tendon?
superior patellar mobs
what is tibial torsion?
twist in the tibial bone
what is a Q angle?
the angle bw femur and the tibia
is the Q angle usually larger in males or females?
females
how do we measure the Q angle?
usually with observation
if measured, measure the angle from the ASIS to the mid patella
t/f: an increase in Q angle can influence patellar problems
true
what is normal patellar tracking?
6mm lateral
3mm medial
what patellar tracking results from increased Q angle, genu valgus, weak VMO, weak hip abductors?
lateral tracking
what patellar abnormality can cause wear on the undersurface of the patella and doesn’t allow good fluid exchange in the articular cartilage?
lateral tilt
t/f: the length of the patella should be the length of the base to the tib tub
true
what is the role of the patella?
to increase the efficiency of the quad by increasing the length for optimal contraction
what can we strengthen and stretch for patellar tracking?
strengthen the quads and hip
stretch the HS
how do we measure leg length with a tape measure?
from the ASIS to the medial malleolus
what is involved in the lower quarter screen?
screening the adjacent joints and neurologic screen of myotomes, dermatomes, and DTRs
what is normal open chain knee flexion?
132-141 degrees
what is normal open chain knee extension?
0-10 degrees
what is normal open chain tibial IR?
20-30 degrees
what is normal open chain tibial ER?
30-40 degrees
what is normal open chain knee abduction?
10-20 degrees
what is normal open chain knee adduction?
10-20 degrees
in the OKC is the femur moving on the tibia or is the tibia moving on the femur?
the tibia is moving on the femur
is the femur or the tibia the concave surface?
the tibia is the concave surface
is the femur or the tibia the convex surface?
the femur is the convex surface
in OKC knee extension, what is the roll and glide?
the tibia rolls anterior and glides anterior
med tib con glides ant
lat tib con glides post
in CKC knee extension, what is the roll and glide?
the femur rolls anterior and glides posterior
med fem con glides post
lat fem con glides ant
in OKC knee flexion, what is the roll and glide?
the tibia rolls posterior and glides posterior
med tib con glides post
lat tib con glides ant
in CKC knee flexion, what is the roll and glide?
the femur rolls posterior and glides anterior
med fem con glides ant
lat fem con glides post
during knee extension, what is the glide of the patella?
superior glide
during knee flexion, what is the glide of the patella?
inferior glide
during IR at the knee, what is the glide of the patella?
medial glide
during ER at the knee, what is the glide of the patella?
lateral glide
what is the capsular pattern at the knee?
flexion loss>extension loss
what is the end feel of knee extension?
elastic, capsular, tissue stretch
what is the end feel of knee flexion?
soft tissue approximation
when we MMT the HS, how can we target the semimembranosus and semitendinosus better?
IR (turn the foot in in prone)
when we MMT the HS, how can we target the biceps femoris better?
ER (turn the foot out in prone)
what should we be palpating at the knee?
the joint line, MCL/LCL, patella, muscles/tendons, edema, and leg length
how can we palpate the MCL better?
prop the leg into valgus
how can we palpate the LCL better?
cross the leg
what are the functional tests?
squatting
stair negotiation
leg crossing
gait assessment
jogging/running assessment
jumping/hopping assessment
one leg hop (time, distance, crossover)
step down
box drop
if a pt complains of knee pain after 2 miles of running, how can we assess their pain at the clinic?
have them get on the treadmill until it provokes their pain and then assess
what are the ACL special tests?
anterior drawer test
Lachman and reverse Lachman test
pivot shift test
what are the special tests for PCL?
posterior drawer test
posterior sag sign
what is the special test for LCL?
varus stress test
what is the special test for MCL?
valgus stress test
what are the tests for ligament dysfunction?
anterior drawer test
Lachman and reverse Lachman test
pivot shift test
posterior drawer sign
posterior sag sign
varus stress test
valgus stress test
what are the stats for the anterior drawer test?
sn: 22-95%
sp: 78-97%
(+) LR: 5.4-8.2
(-) LR: .09-.62
.34-.54 kappa
how do we perform the anterior drawer test?
in supine hooklying, sit on their foot to stabilize the foot
grab behind the calf near the jt line and pull forward on the tibia
should feel excursion and hard end feel of the ACL
feel unaffected side to feel their normal
if an anterior drawer test produces pain and laxity, what may this indicate?
could be a partial tear of the ACL
if an anterior drawer test produces laxity and no pain, what may this indicate?
could be a full tear
what are the stats of the Lachman and reverse Lachman test?
sn: 63-99%
sp: 42-100%
(+)LR: 1.12-27.3
(-)LR: .04-.83
how do we perform the Lachman test?
in supine flex the knee to 30-35 deg
stabilize the femur and grab the tibia behind the calf and yank forward
feel the anterior jt line with your thumb
should feel excursion and hard end feel of the ACL
how do we perform a reverse Lachman test?
in prone, flex the knee to 30-35 deg
pull back on the tibia in line with the jt
what is a positive anterior drawer test?
pain and or laxity
what is a positive Lachman and reverse Lachman test?
pain and or spongey end feel of the ACL
if there is a pop at the time of injury, the MOI is non-contact, and there is immediate swelling, what is the likely injury?
ACL injury
what are the stats of the pivot shift test?
sn: 18-98%
sp: 97-99%
(+)LR: 4.2-41
(-)LR: .18-.35
how do we perform the pivot shift test?
IR with valgus forces into flexion
ER w/valgus into extension
what is a positive pivot shift test?
with IR and valgus force into flexion, there is a clunk out of place at about 30 deg flexion
with ER and valgus force into extension, there is a clunk back into place at about 30 deg flexion
what are the stats of the posterior drawer test?
sn: 25-90%
sp: 99%
(+)LR: 90
(-)LR: .10
how do we perform the posterior drawer test?
in supine hookyling
push back on the tibia just below the jt line
should feel excursion then hard end feel of the PCL
what is a positive posterior drawer test?
pain and or laxity
what are the stats of the posterior sag sign
sn: 46-100%
sp: 100%
how do we perform the posterior sag sign?
at 90/90 hip/knee flexion observe the level of the tib tub (should be roughly at the same height of the patella)
what is a positive posterior sag sign?
the tib tub drops below the level of the patella
when could we get a false positive anterior drawer test?
if someone has a positive posterior sag sign
what are the stats of the varus stress test?
sn: 25%
.88 kappa
how do we perform the varus stress test?
at 15-25 deg knee flexion, push the knee at the tibia into varus
what are the stats of the valgus stress test?
sn: 86-96%
.02-.66 kappa
how do we perform the valgus stress test?
at 15-25 deg knee flexion, push the knee at the tibia into valgus
what are the tests for meniscal dysfunction?
McMurray test (+ heel to buttock test)
Thessaly test (+ Appley test)
what are the stats of the McMurray test?
sn: 16-95%
sp: 25-98%
(+)LR: .39-8.0
(-)LR: .83-2.84
.35-.95 kappa
what is the heel to buttock test?
overpressure into hip/knee flexion
what test can be combined with the McMurray test?
the heel to buttock test
how do we perform the McMurray test for the medial meniscus?
ER tibia and valgus force at the knee
hand at the ankle, palm at the medial knee while feeling the jt line
how do we perform the McMurray test for the lateral meniscus?
IR tibia and varus force at the knee
hand at the ankle, palm at the lateral knee while feeling the medial jt line
what is a positive McMurray test?
pop and/or pain (document if it’s one or both)
what test should we do before the McMurray?
the varus/valgus stress test to rule in/out MCL/LCL
if you perform the varus/valgus stress test and McMurray and they are both positive, what may this indicate?
it could be MCL/LCL or meniscus
if you perform the varus/valgus stress test and McMurray test and the varus/valgus stress test is negative, but McMurray is positive, what may this indicate?
more likely a meniscus injury
what are the stats of the Thessaly test?
sn: 66-81% (at 5 deg) ; 89-92% (20 deg)
sp: 91-96% (at 5 deg) ; 96-97% (20 deg)
(+)LR: 6.8-16.5 (5 deg) ; 23.29.7 (20 deg)
(-)LR: .21-.76 (5 deg) ; .08-.11 (20 deg)
reliability= .95
how do we perform the Thessaly test?
excessive force at the knee with rotation
single leg stance w/5-20 deg knee flexion, arms crossed, and twisting the whole trunk/pelvis to grind the knee
what is a positive Thessaly test?
crepitus, pop, and/or pain
what is the OKC Thessaly test?
the Appley test
how do we peform the Appley test?
in prone, flex the knee to 90 deg and apply compression and grinding
what is a positive Appley test?
crepitus, pop, and/or pain
what are the tests for patellofemoral dysfunction?
apprehension test
moving patella apprehension test
what are the stats of the apprehension test?
sn: 7-39%
sp: 70-92%
(+)LR: .87-2.3
(-)LR: .79-1.0
how do we perform the apprehension test?
push the patella laterally to see if the pt is apprehensive
what is a positive apprehension test?
the pt is apprehensive that the patella will pop laterally
what are the stats of the moving patella apprehension test?
sn: 100%
sp: 88.4%
how do we perform the moving patella apprehension test?
push the patella laterally and extend the knee to see if the pt is apprehensive
can push the patella medially and see if it feels better
what is a positive moving patella apprehension test?
the pt is apprehensive that the patella will pop off laterally
if the HS are tight, the quads have to work harder which may lead to what?
patella compression and pain
what is the lunge test?
have the pt lunge in dif positions and listen for a pop or crepitus
what are the tests for ITB dysfunction?
Ober test
Noble test
Renne test
how do we perform the Renne test?
have the pt in single leg stance and do mini squats while you palpate the ITB insertion at the knee
what is the test for fractures?
Ottowa knee rules
what are the Ottowa knee rules that may rule in/out a fx?
> 55 y/o
tender patella or fibular head
unable to flex the knee >90 deg
inability to take 4 steps
what are the stats of the Ottowa knee rules for adults?
sn: 98-100%
sp: 19-54%
what are the stats of the Ottowa knee rules for children?
sn: 92%
sp: 49%
what are the (+)LR of the Ottowa knee rules?
> 10=conclusive inc in likelihood
5-10=mod Inc in likelihood
2-5=small inc in likelihood
1-2=min inc in likelihood
1=no change in likelihood
if the (+)LR of the Ottowa knee rules is >10, what does this mean?
conclusive inc in likelihood
if the (+)LR of the Ottowa knee rules is 5-10, what does this mean?
mod inc in likelihood
if the (+)LR of the Ottowa knee rules is 2-5, what does this mean?
small inc in likelihood
if the (+)LR of the Ottowa knee rules is 1-2, what does this mean?
min inc in likelihood
if the (+)LR of the Ottowa knee rules is 1, what does this mean?
no change in likelihood
if the (-)LR of the Ottowa knee rules is .5-1, what does this mean?
min Dec in likelihood
if the (-)LR of the Ottowa knee rules is .2-.5, what does this mean?
small Dec in likelihood
if the (-)LR of the Ottowa knee rules is .1-.2, what does this mean?
mod Dec in likelihood
if the (-)LR of the Ottowa knee rules is <.1, what does this mean?
conclusive Dec in likelihood
what are the (-)LR of the Ottowa knee rules?
.5-1=min Dec in likelihood
.2-.5=small Dec in likelihood
.1-.2=mod Dec in likelihood
<.1=conclusive Dec in likelihood
