Knee, Ankle, and Foot Pain

Question 1

When obtaining a history for knee pain, it’s important to obtain what?

Answer 1

Mechanism of injury
Characteristics of the pain in the knee
Mechanical symptoms (i.e., popping, locking, instability)
Inspection of swelling, bruising, etc.

Question 2

Are we born naturally with genu varus or genu valgum?

Between ages 2-4, it switches it what?

What age is does it return to normal adult alignment?

Answer 2

Born with genu varus

Becomes more genu valgum between 2-4

By age 7, we decrease to a slight genu valgum, which is normal

Question 3

What could cause rickets, blount’s disease (abnormal formation of the proximal tibia), skeletal dysplasia, etc.?

Answer 3

Genu varus (AKA bow-legs)

Question 4

What is caused by intrauterine molding, Cozen fracture, or obesity, and could present with pain on medial side of foot or knee

Answer 4

Genu valgum

Question 5

A 23 yo presents to ER w/ R knee pain. After kicking soccer ball, he pivoted his leg to the right and heard a loud pop before feeling severe pain at the knee. You also notice swelling. He tests positive for Lachman’s and the anterior drawer test.

Differential?

Answer 5

ACL injury or tear

Question 6

What type of ligament injury or tear is thought of as uncommon due to it being the strongest and largest of the knee ligaments, and would cause a positive posterior drawer test and sag sign

Answer 6

PCL injury or tear

Question 7

A 15 yo presents w/ knee pain that started 2 hours ago. Felt sudden pain just as he was trying to run to second base while his shoe was caught on first base. He has pain and swelling of the knee as well as increase in laxity when compared bilaterally. He tests positive with valgus stress test.

Differential?

Answer 7

MCL injury

Question 8

Which of the collateral ligament injuries is least common and can be tested for with a varus stress test or dial test.

Answer 8

LCL injury

Question 9

57 obese female presents w/ pain on right inner aspect of knee after bending down to pick up a cat. She states it feels like her knee will “give way.” On exam, knee is swollen and tender to palpation, you perform a McMurray test and an Apley grind test, both result in a positive.

Differential?

Answer 9

Meniscal injury.

Usually caused by twisting injuries

Question 10

22 yo F ballroom dancer presents w/ pain on anterior aspect of her knee. She states she has been training nonstop for the last 2 months. Knee appears normal but pain is elicited by palpating the patella and moving it laterally and medially. You have her squat which results in pain, and additionally perform an apprehension test by patellar glide, which also yields a positive result.

Differential?

Answer 10

Patellofemoral pain

Question 11

What is the most common cause of knee pain in primary care?

Answer 11

Patellofemoral pain

Question 12

53 yo F morbid obesity w/ PMH of HTN, T2D, sleep apnea presents w/ progressively worsening bilateral knee pain. No obvious swelling noted. Her ROM is maintained, but is painful. She does have crepitus noted w/ flexion and extension of the knee.

Differential?

Answer 12

OA

Question 13

13 yo M brought in by mom after several weeks of anterior knee pain. Pt is active, and states pain is more severe w/ activity. Mild swelling of anterior knee and pain with ROM.

Differential?

Answer 13

Osgood Schlatters

Question 14

What are the Ottawa knee rules, and what are they used for.

Answer 14

1. Age 55 years or older
2. Tenderness @ head of fibula
3. Isolated tenderness of patella
4. Inability to flex knee to 90°
5. Inability to walk four weight-bearing steps immediately after the injury and in the ED

If pt meets any of these rules, you need to order an XR

Question 15

Ottawa knee rule and Pittsburgh rule are both […]

Answer 15

Sensitive

Question 16

53 yo F w/ T2D presents w/ complaints of pins and needles on both feet. Pt has had diabetes for 8 years and blood sugars have fluctuated as she has not cut back on her carbs. The physician is concerned the diabetes has affected her feet. What can he do to assess (3 things)?

Answer 16

Pressure sensation using monofilament testing

Vibration sensation using tuning fork

Superficial pain using pinprick

REMEMBER: A complete diabetic foot exam includes pulses, checking for skin lesions (don’t forget to check between the toes)

Question 17

16 yo F presents to office 1 hour after injuring her right foot while trying to hit a soccer ball. Instead of hitting the soccer ball, her foot rolled inward. Mild swelling and tenderness over lateral ankle. Pt tested positive for anterior drawer test and talar tilt test. What structure is affected, and what is possible differential?

Answer 17

Ankle sprain

Question 18

16 yo F presents to office 1 hour after injuring her right foot while trying to hit a soccer ball. Instead of hitting the soccer ball, her foot rolled inward. Mild swelling and tenderness over lateral ankle. Pt tested positive for squeeze test. What structure is affected, and what is possible differential?

Answer 18

Syndesmotic ankle injury

Question 19

36 yo nurse w/o PMH presents w/ pain localized to the left heel, especially when she walks on her kitchen tile barefoot after getting off of a 12 hour shift the night prior. You note she has pain with passive dorsiflexion.

Differential

Answer 19

Plantar fasciitis

Question 20

41 yo F presents w/ pain in feet. Pain is localized between 3rd and 4th toes. She usually is wearing heels. You test positive for Mulder’s sign (clicking sensation when palpating the 3rd intermetatarsal space).

Differential?

Answer 20

Morton’s neuroma

Question 21

72 yo male w/ PMH of HTN, DM, gout, sleep apnea presents with pain and swelling of great toe. He states it started 2 days ago w/ mild tenderness, but has slowly increased in pain. He states now a blanket grazing his toe is extremely painful. You palpate and it is warm to touch and erythematous.

Differential?

Answer 21

Gout