Knee Ankle Foot Pain

Question 1

Valgus test

Answer 1

Pt supine with knee flexed to 30 degrees
Physician supports lower leg itch one hand and other hand placed on the lateral aspect of the pt’s knee
Apply a medial force to the proximal tibia while abducting the lower leg
(+) test: increased laxity, soft or absent endpoint, pain
Indication: medial collateral ligament disruption
If positive when knee fully extended, indicates more serious injury, probably joint capsule

Question 2

Varus test

Answer 2

Pt supine with knee flexed to 30 degrees
Physician supports the lower leg with one hand and other hand placed on the medial aspect of the pt’s knee
Apply a lateral force to the proximal tibia while adducting the lower leg
(+) test: increased laxity, soft or absent endpoint, pain
Indication: lateral collateral L. Disruption

Question 3

Anterior/posterior drawer test

Answer 3

Pt supine with knee flexed to 90 degrees
Physician sits on the pt’s foot and grasps the proximal tibia with both hands, pulling the tibia anteriorly/posteriorly
(+) test: excessive translation
Indicates: ACL/PCL injury

Question 4

Lachman’s test

Answer 4

Pt supine
Physician places cephalad hand on the distal thigh, superior to patella
Caused hand grasps the proximal tibia
Flexing the knee to 10-30 degrees, the examiner uses his caudate hand to pull the tibia anteriorly while the cephalad hand stabilizes the hand
More sensitive test
(+) test: increased laxity, soft or absent end point
Indicates: ACL injury

Question 5

Reverse Lachman’s test

Answer 5

Pt supine
Physician places cephalad hand on the distal thigh, superior to patella
Causal hand grasps the proximal tibia
Flexing the knee to 10-30 degrees; proximal hand stabilizes the femur while the distal hand pushes the tibia posterior
Mores sensitive test
(+) test: increased laxity, soft or absent end point
Indication: PCL injury

Question 6

McMurray’s test

Answer 6

Pt supine, with hip and knee flexed; examiner uses caudad hand to control the ankle and cephalad hand placed on distal femur
Lateral meniscus: examiner rotates the tibia into IR and applies a varus stress, then continues the leg into extension
Medial meniscus: examiner rotates the tibia into ER and applies a valgus stress, then continues the leg into extension
(+) test: pain or palpable click during extension
Indication: medial or lateral meniscus tear

Question 7

Apley’s Grind test-compression test

Answer 7

Pt prone with knee flexed to 90 degrees
Examiner uses downward force on that foot to provide a compressive force on the meniscus, while rotating the foot internally and externally
(+) test: pain with rotation and/or compression
Indication: possible meniscal injury, collateral ligament injury, or both

Question 8

Apley’s grind test-distraction test

Answer 8

Pt is in same position for the compression
Examiner stabilizes the thigh then applies upward traction to the leg while rotating it
(+) test: pain with distraction and rotation, increased ligamentous strain; indication: possible collateral ligament damage
(+) test: relief of pain with distraction and rotation, reduced meniscal pressure; indication: possible meniscus injury

Question 9

Patellar laxity and apprehension tests

Answer 9

Laxity test: one hand above and one hand below the joint; thumbs placed against the medial side of the patella; examiner pushes the patella laterally, assessing ROM
Apprehension test: when testing laxity to the point of restriction, ask the pt if the maneuver provokes any discomfort or sense of instability
(+) test: sense of apprehension or instability
Indication: possible previous patellar dislocation or severe instability

Question 10

Patellar Compression (grind) test

Answer 10

Pt supine and knee extended
Provide compressive load to the patella with one hand while moving the patella medial and lateral
(+) test: pain with compression
Indication: possible inflammation, chondromalacia, or injury to the patellofemoral articular surfaces

Question 11

Patella-femoral grinding test

Answer 11

Compress patella causally into trochlear groove and instruct pt to tighten quadriceps against resistance
(+) test: crepitus or pain
Indication: roughness of articulating surfaces (chondromalacia)

Question 12

Patellar glide test

Answer 12

Pt sitting or supine will slowly extend and flex the knee, while physician notes quality of the articular motion
Pacing hand lightly over the patella can increase sensitivity of the test
(+) test: palpable or audible crepitus, pain, or catching of the patella
Indication: possible damage to the articular surface

Question 13

Anterior drawer test (ankle/foot)

Answer 13

Grasp posterior calcaneus with one hand and distal tibia/fibula with the other hand, monitoring anteriorly at the anterior talus
Provide anterior force on calcaneus while stabilizing the distal tibia/fibula
Normal springing of calcaneus back to neutral should occur
(+) test: pain, no springing, excessive motion/laxity
Indication: ATF ligament pathology/tear

Question 14

Talar tilt test

Answer 14

Grasp distal tibia/fibula with one hand and inferior calcaneus with the other, blocking motion of the calcaneus on the talus
Invert the talus to evaluate ROM
(+) test: laxity, increased ROM, or pain
Indication: calcneofibular L. Pathology/tear, also tests some ATF

Question 15

Eversion test (foot/ankle)

Answer 15

Grasp distal tibia/fibula with one hand and plantar surface of the mid-foot with the other hand
Evert the foot to evaluate ROM
(+) test: laxity, increased ROM or pain
Indication: deltoid ligament pathology

Question 16

Squeeze test

Answer 16

Wrap hands around leg proximal to the ankle, contacting distal tibia/fibula with both thenar eminences
Squeeze for 2-3 seconds, then rapidly release
(+) test: pain at syndesmosis
Indication: syndesmosis pathology (high ankle sprain)

Question 17

Cross leg test

Answer 17

Pt crosses affected ankle over opposite knee
Apply pressure to distal fibula of affected eg
(+) test: pain at distal ankle
Indication: high ankle sprain

Question 18

Thompson test

Answer 18

Pt prone with foot off the table
Squeeze the pt’s calf, observe for plantarflexion
(+) test: absence of plantar flexion
Indication: Achilles’ tendon rupture

Question 19

Homan’s sign

Answer 19

Pt laying or seated with knee extended
Dorsiflexion the pt’s foot, can apply lateral compression to calf
(+) test: pain with dorsiflexion
Indication: thrombophlebitis or acute deep vein thrombosis (DVT)
Accompany signs of edema, erythema, and warmth of the lower leg
Would need to order a Venous Doppler to rule out clot

Question 20

Moses sign

Answer 20

Pt seated or supine with knee slightly flexed or extended
Induce an anterior compression on the gastrocnemius muscle into the posterior aspect of the tibia (compresses the calf towards the tibia)
(+) test: pain with anterior compression
Indication: DVT

Question 21

Inversion ankle sprain

Answer 21

Anterior talofibular L.
80-8% of all ankle sprains
Ankle inversion with plantar flexion

Question 22

High ankle sprain

Answer 22

10% of all ankle sprains
Ankle eversion and rotation (some dorsiflexion)
Anterior inferior tibiofibular L.
Syndesmosis
Pain more common on medial aspect with minimal swelling, pain worse with weight bearing

Question 23

Morton’s neuroma

Answer 23

Inflammation and thickening of tissue that surrounds the nerve between toes
Most commonly between 3rd and 4th toes
Pt reports feeling like they are walking on a marble
Palpable in web space, which will replicate burning pain
Can have radiation of pain and numbness of toes
Test: Mulder’s sign: clicking sensation upon palpating with one hand the third web space and other hand compressing the transverse arch together

Question 24

Turf toe

Answer 24

Inflammation and pain at base of 1st MTP
Presents as pain and bruising at base of great toe
Caused by hyperextension of great toe causing damage to the joint capsule; severe cases can damage sesamoid and flexor tendon
Commonly associated with activities performed on hard surface

Question 25

Diabetic neuropathy

Answer 25

Complication of diabetes causing gradual loss of nerve fibers, presenting as loss of vibratory sensation along with impaired pain, light touch, and temp sensations
Test pressure sensation using a monofilament test, vibration sensation using a tuning fork, and superficial pain using pinprick
Complete diabetic foot exam includes examining pulses, checking for skin lesions

Question 26

Monofilament test

Answer 26

Done for diabetic neuropathy of the foot
Performed on the plantar aspect of foot
Physician asks pt to close their eyes
The monofilament is placed on the first and third pad of toes and at base of first, third, and fifth plantar MTP joints
Use enough pressure to cause a slight bend of the monofilament
Test is positive if pt cannot feel the monofilament

Question 27

Gout

Answer 27

Precipitation of mono sodium irate crystals in joint space causing an inflammatory response
Most commonly affects the first MTP joint but can also affect the mid-tarsal joints, ankles, knees, and/or fingers
Swollen, tender, erythematous, and painful joint upon presentation

Question 28

Ottawa Ankle Rules

Answer 28

Acute ankle injuries to rule out ankle fracture
An ankle series is only indicated for patients who have pain in the malleolar zone and have bone tenderness at the posterior edge or tip of the lateral or medial malleolus
OR
Are unable to bear weight both immediately after the injury and for four steps in the ED or doctor’s office

Question 29

Foot series (Ottawa Ankle rule)

Answer 29

Only indicated for pts who have pain in the mid foot zone and have bone tenderness at the base of the fifth metatarsal or at the navicular
OR
Are unable to bear weight both immediately after the injury and for four steps in the ED

Question 30

Rules for use of the Ottawa ankle rules

Answer 30

If the pt can transfer weight twice to each foot (four steps), he or she is considered able to bear weight even if he or she limps
Palpate the distal 6 cm of the posterior edge of the fibula when assessing for bone tenderness