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Orthopedic Diagnostics > Knee Assessment > Flashcards

Knee Assessment Flashcards

1
Q

What types of questions could you ask for knee assessment history?

A
  • MOI: traumatic vs. insidious
  • Did the patient hear or feel a click/pop at time of injury?
  • Was there significant swelling immediately post injury?
  • Does the knee lock or give way?
  • What motions hurt the knee? Twisting? Kneeling?
  • Is there crepitus?
  • Where is the pain located? Does it change?
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2
Q

Knee Observation

A

a. Obvious swelling or effusion
b. Positon of the patella
c. Genu varus/valgus
d. Q angle
e. Position of hip and foot in relation

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3
Q

What are the special tests (stress tests) for the ACL?

A
  1. Posterior SAG test (do this first before anterior drawer so that you do not get a false positive for ACL when it is actually PCL)
  2. Anterior Drawer Test
  3. Lachman’s Test
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4
Q

What are the PCL stress tests?

A
  1. Posterior drawer test
  2. Posterior sag test
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5
Q

What is the MCL/Valgus stress test?

A
  1. Patient is supine with hip slightly abducted and extended
  2. Knee is flexed at 30 degrees
  3. Examiner places one hand on the lateral aspect of the knee and the other on the lower leg
  4. Gently apply a lateral to medial force to the knee, while hand at the anklge externally rotates the leg to snug it up
  5. Repeat test in full extension and at 90 degrees flexion
  6. Positive test is excessive medial openeing and concordant pain when compared to the uninvolved knee. If test is positive at 30 degrees the MCL is implicated. If the test is positive at 0 degrees the ACL/PCL and or joint capsule may be implicated
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6
Q

Describe the LCL/Varus stress test

A
  1. Patient is supine with hip slightly abducted and extended so teh thigh is resting on the surface of the table
  2. Knee is flexed 30 degrees over the side of the table and examiner is positioned medial to leg.
  3. Examiner places one hand about the medial aspect of the knee while the other hand grasps the foot/ankle
  4. Repeat test with knee in full extension
  5. A positive test is excessive lateral opening and concordant pain. If test is positive at 30 degrees the LCL is implicated. If the test is positive at 0 degrees, the ACL/PCL and or joint capsule is implicated
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7
Q

What are the special tests for the meniscus? What basic signs do you look for?

A
  1. Joint line tenderness
  2. McMurray test
  3. Apley’s test

Look for swelling and locking

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8
Q

Describe the Joint Line Tenderness test

A
  1. Patient supine with affected knee flexed to 90 degrees
  2. Examiner palpates medial and lateral tibiofemoral joint line
  3. Positive test for meniscus tear is indicated by reproduction of the patient’s pain
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9
Q

Describe the McMurray test. Describe for both medial and lateral meniscus.

A
  1. Patient supine. Examiner stands to side of patient’s involved knee
  2. Examiner grasps patient’s heel and flexes the knee to end range with one hand while using thumb and index finger of other hand to palpate the medial and lateral tibiofemoral joint line
  3. To test medial meniscus, examiner externally rotates tibia, while slowly extending the knee
  4. To test lateral meniscus, examiner internally rotates teh tibia, while slowly extending the knee
  5. A positive test is indicated by an audible or palpable thud or click
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10
Q

Describe Apley’s test. Describe the distraction vs compression components

A
  1. Patient lies prone.
  2. Examiner half-kneels, placing knee on hamstring of patient and flexes knee to 90 degrees
  3. Examiner grasps patient’s foot with both hands, distracts the tibia and rotates the tibia, noting whether or not pain is reproduced
  4. Positive test is indicated by worse pain with rotation and is indicative of a “rotation sprain” of soft tissue.
  5. This a sort of “catch all” test for knee sprains and is not specific.
  6. Patient lies prone with affected knee flexed to 90 degrees
  7. Compression component: Examiner leans on patient’s foot, providing a compressive force to the tibia and rotates the tibia
  8. Positive test for meniscus tear is indicated by more pain in compression than with distraction
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11
Q

What are the patellar femoral dysfunction tests?

A
  1. Clarke’s sign
  2. Patella mobility testing
  3. Jumper’s knee (tendinopathy)
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12
Q

Clarke’s Sign (Patellar Grind/Patellar Tracking with Compression)

A
  1. Patient positioned supine with both knees slightly flexed, can be supported by low knee pad or bolster
  2. Examiner places a hand on the superior border of the patella and presses the patella distally while the patient is relaxed
  3. Patient is asked to contract the quadriceps (can aske patient to lift their heel off the table)
  4. Positive test is pain and reproduction of symptoms
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13
Q

Describe Patella Mobility Testing

A
  1. Patient is positioned in long seated position with knees slightly flexed
  2. The patella is pushed medially/laterally and superiorly/inferiorly
  3. The patella should have motion in each direction that is equivalent to half it’s width
  4. Positive test is indicated by decreased motion when compared to uninvolved side.
  5. Examiner can also perform at ilt of the inferior patellar pole by pushing on the base (top) of the patella
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14
Q

Describe the Jumper’s Knee test (palpation for tendinopathy)

A
  1. Examiner tilts the inferior pole of the patella anteriorly by pushing on the base (top) of the patella
  2. Examiner palpates on and around the inferor pole of the patella
  3. Positive sign is indicated by reproduction of the patient’s knee pain
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15
Q

What is a test for the IT band?

A

Nobel’s Compression Test:

  1. Patient lies supine with knee flexed
  2. Examiner grasps above the tibiofemoral joint line and places pressure on the lateral side over top of IT band
  3. Examiner extends the knee passively while applying pressure
  4. Examiner feels for IT band snapping over lateral femoral condyle (at 20-30 degrees of flexion usually) or patient complaining of pain reproduction
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16
Q

What are the Ottawa Knee Decision Rules for a fracture at the knee?

A
  1. Age greater than or equal to 55
  2. Tenderness at the head of the fibula
  3. Isolated tenderness of the patella
  4. Inability to flex the knee to at least 90 degrees
  5. Inability by the patient to bear weight both immediately and in the emergency department for four steps

A positive test is the presence of any one of the four characteristics and is an indication for referral for an x-ray to confirm a fracture.

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17
Q

What sinew channels are most important for knee problems?

A
  • Bladder
  • Stomach
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18
Q

What is pes anserine bursitis?

A

Pes anserine consists of three muscles: sartorius, gracilis, semitendinosus

These support the medial aspect of knee and attach medial anterior tibia, medial to tibial tuberosity and a little bit lower. Just underneath there is a bursa. If you palpate up and find tenderness on the medial side you might be thinking pes anserine. A cause of medial knee pain that is underdiagnosed as people mostly think meniscus and MCL.

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19
Q

Describe the ACL. What is its function?

A

The ACL, originating from deep within the notch of the distal femur on the lateral condyle, runs in an anteromedial direction to attach in front of the intercondylar eminence of the tibia on the tibial plateau (blends with the medial meniscus).

Function: To resist anterior translation and medial rotation of the tibia in relation to the femur

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20
Q

What are the two bundles of the ACL? What are the functional differences?

A

There are two bundles of the ACL (named according to where the bundles insert into the tibial plateau.):

a) The anteromedial – taut in flexion
b) The posterolateral – taut in extension
- more involved with rotational instabilities

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21
Q

The ACL provides ____ percent of the restraining force to anterior tibial displacement at ____ and ____ degrees of knee flexion. Prevents hyperextension.

A

85 %

30 and 90 degrees

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22
Q

What are the most common MOI’s for ACL rupture?

A
  • Cutting, twisting or pivoting in sports with or without contact.
  • Rapid deceleration
  • Heavy/stiff-legged landing or landing flat on their heels. The straight-knee position places the anterior femoral condyle on the back-slanted portion of the tibia. The resultant forward slide of the tibia relative to the femur is restrained primarily by the now-vulnerable ACL.
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23
Q

What are risk factors for ACL rupture?

A
  1. Females typically have a greater quadriceps angle or Q-angle.Q-angle is the angle measured between the anterior superior iliac spine and patellar ligament. A greater Q angle places an increased valgus force on the knee, increasing the activation of the quadriceps muscles.
  2. Muscle imbalance, quadriceps dominance: Weakness in the hamstrings or reliance on the strength of the quadriceps muscles will increase the anterior shear of the tibia on the femur
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24
Q

What are the signs of an ACL rupture? Include special tests. What is the difference between a partial and full tear diagnostically?

A
  1. Swelling – Significant if seen immediately post trauma.
  2. Decreased ROM – either from pain (empty endfeel) or excess swelling in the joint.
  3. Positive ligament stability testing- Lachmans (p.445), Anterior Drawer (p. 446-447).
  4. Negative Posterior sag test (p.453).

Note: Partial Tears will mimic full ACL tears with exception of a firm endfeel.

25
Q

What is the posterior cruciate ligament antaomy and function?

A

Originating from the lateral edge of the medial femoral condyle and the roof of the intercondylar notch, the PCL travels in a posterolateral direction to insert on the posterior tibia just below its articular surface.

Function: Resist posterior tibial shear on the femur. Prevents hyperflexion (posterior translation of the tibia on the femur or anterior translation of the femur on the tibia).

26
Q

What are the functional differences between the anterolateral band of the PCL and the posteromedial bundle?

A

During knee joint movement, the PCL rotates such that the two bands resist opposite movements:

a) The anterolateral band stretches in knee flexion (tightens) but not in knee extension.
b) The posteromedial bundle stretches in extension (tightens) rather than flexion.

27
Q

What is the most common cause of a PCL rupture?

A

Common cause is a direct blow to the flexed knee, such as the knee hitting the dashboard in a car accident or falling hard on the knee (especially if on a step)

28
Q

What are the primary signs of a PCL rupture? Include special tests.

A
  1. Swelling – Significant if seen immediately post trauma.
  2. Decreased ROM – either from pain (empty endfeel) or excess swelling in the joint.
  3. Positive ligament stability testing- Posterior sag (p.453), Posterior drawer (p.452).
29
Q

What is the medial collateral ligament and what is it’s function?

A
  • Originates proximal to the medial epicondyle of femur immediately below the adductor tubercle and runs in an inferior medial direction. The superficial fibers attach to and distal to the medial condyle of the tibia and the deep fibers attach to the medial meniscus.
  • Embryologically the ligament represents the distal portion of the tendon of adductor magnus. Because of this, the ligament occasionally contains muscle fibers.

Function: Provides medial/valgus support to the knee

30
Q

What is the MOI of an MCL injury?

A
  • Any excessive medial/valgus force, most often to a slightly bent knee.
  • Lateral impact to the knee
  • Football cleats are a common cause
  • Chronic MCL strains are common in professional swimmers, esp breaststroke
31
Q

What would one see on assessment of an MCL injury? What test is important?

A
  • Minimal to no swelling
  • Tender on palpation to MCL
  • Restricted ROM secondary to pain
  • Positive MCL stress test (positive at 30 degrees)
32
Q

If someone has tenderness right on the tibiofemoral joint line what should you be thinking of?

A

If they are just tender on the joint line right after injury be more suspicious of a meniscus injury. Coronary ligaments, little ones that attach meniscus down to the bone on the periphery of the joint can be sprained without tearing the meniscus.

Joint line tenderness could also be end phases of healing MCL, usually lateral joint line is the last part to heal.

33
Q

What is the anatomy and function of the lateral collateral ligament?

A

Anatomy: runs obliquely in an inferior and posterior direction from the lateral epicondyle of the femur to the head of the fibula.

This ligament is separate from the joint line itself. In a cadaver you can actually put a finger between LCL and the joint if you take out all of this other tissue (Bursa, Oblique ligaments, Fat tissue)

Function: Provides lateral/varus support to the knee

34
Q

What is the MOI of an LCL injury?

A

Any excessive lateral/varus force on the knee, often in hyperextension.

Note: A hyperextension injury can lead to an LCL injruy as well as ACL.

35
Q

What will be seen on assessment of an LCL injury?

A
  • Minimal – no swelling
  • Tender on palpation to LCL
  • Restricted ROM secondary to pain
  • Positive LCL stress test (positive at 30 degrees)
36
Q

What is the anatomy of the meniscus?

A

Crescent shaped fibrocartilage that provides structural integrity to the knee when it undergoes compression and torsion.

Blood flow of the meniscus is from the periphery to the centre. Blood flow decreases with age and the central meniscus is avascular by adulthood.

37
Q

What is the MOI for a meniscal tear?

A

Combination of compression and twisting

38
Q

What are the two general types of meniscus injuries?

A
  1. Acute tears: often the result of trauma or a sports injury (vertical, horizontal, radial, oblique, complex).
  2. Chronic or wear-and-tear type tears: often the result of repetitive flexion/extension while weight bearing, higher prevalence in jobs that require a twisting or rotation motion as well.
39
Q

What are general assessment findings for meniscal injuries?

A
  • Trouble weight bearing
  • Painful to weight bear and twist (duck walk)
  • Tender on palpation to joint line
  • Positive McMurray and Apley tests
40
Q

•A 2008 study in the New England Journal of Medicine shows that about ____ percent of meniscus tears cause no pain and are found in asymptomatic subjects.

A

60%

41
Q

What is the terrible/unhappy triad?

A

Simulataneous tearing of ACL, MCL and medial meniscus. Stereotypical football or rugby injury. Valgus stress, decelerating, twisting and someone tackles from the side.

42
Q

What is patellofemoral pain syndrome?

A

Anterior knee pain involving the patella and femoral condyles that excludes other intra-articular and peri-patellar (tendons, ligaments or bursa around knee) pathology.

43
Q

What are the causes of PFPS?

A

The cause of PFPS is thought to be increased pressure on the patellofemoral joint, due to one or more of the following…

  1. Overuse. Bending the knee moves the patella tighter against the femur. Patellofemoral pain syndrome worsens with activities that put weight on the knee while it is bent, such as squatting or running on steps and hills.
  2. Malalignment of the patella as it moves through the femoral groove
  3. Poor hip mechanics resulting in an increased Q angle.
  4. Muscle imbalances: Tight hamstrings, calves, and hip muscles increase the pressure between the kneecap and the thighbone. Of the four muscles that make up the quadriceps, three pull the kneecap toward the outside; if the innermost quadriceps muscle is relatively weak, this can create tracking problems.
  5. Tight anatomical structures, e.g. retinaculum or iliotibial band.
44
Q

What are the symptoms of PFPS?

A
  • ·Knee pain - the most common symptom is diffuse peripatellar pain (vague pain around the kneecap) and localized retropatellar pain (pain focused behind the kneecap). Affected individuals typically have difficulty describing the location of the pain, and may place their hands over the anterior patella or describe a circle around the patella (the “circle sign”). Alternatively, patients may indicate pain that is inside the knee, pointing to the patella.
  • Pain is usually initiated when load is put on the knee extensor mechanism, e.g. ascending or descending stairs or slopes, squatting, kneeling, cycling, running or prolonged sitting with flexed (bent) knees.
  • The pain is typically achy, occasionally sharp.
  • Crepitus may be present
  • Possible giving-way of the knee
  • Unless there is an underlying pathology in the knee, swelling is usually mild or nonexistent.
45
Q

Differential diagnosis for PFPS?

A
  • Chondromalacia patellae: similar to PFPS but also with cartilage degeneration. If Clarke’s test is postive with crepitus you might think of this.
  • IT Band syndrome
46
Q

What sinew channel would we look to for PFPS?

A

Stomach

47
Q

What is the iliotibial band?

A

The iliotibial band is a thick band of fascia on the lateral aspect of the leg. It extends from the Gluteus Maximus and Tensor Fascia Latae on the hip to insert on the lateral aspect of the patella via the patella retinaculum and more distally on the lateral tibia (on gerdy’s tubercle). It also has an insertion on the linea aspera via an intermuscular septum through vastus lateralis.

48
Q

What is the etiology of IT Band syndrome?

A

The continual rubbing of the band over the lateral femoral epicondyle with repeated flexion and extension of the knee (aprox 30 degrees) during activity may cause the area to become inflamed and painful. Fascial septum that attaches to linea aspera, tightness in VL can also contribute to IT band issues.

49
Q

What are symptoms of IT Band syndrome?

A
  • Stinging sensation just above the knee joint, which may be felt just on the outside of the knee or along the entire length of the ITB.
  • Swelling or thickening of the tissue in the area where the band moves over the femur.
  • Pain may not occur immediately during activity, but may intensify over time. Pain is most commonly felt when the foot strikes the ground, and pain might persist after activity.
  • True IT Band friction Syndrome: Very localized sharp pain where IT band passes over lateral femoral condyle as it goes into 20-30 degrees flexion and extension. Often long distance runners and cyclers who get this.

.

50
Q

What are some causes of IT Band syndrome?

A

The band is crucial to stabilizing the knee during running, as it moves from behind the femur to the front of the femur during activity. ITBS can result from one or more of the following:

Ø training habits (eg. always running one way on a track)

Ø muscular imbalances.

Ø anatomical variations/abnormalities,

51
Q

Give examples of training habits that may contribute to IT band syndrome.

A
  • Consistently running on a horizontally banked surface (such as the shoulder of a road or an indoor track).
  • Inadequate warm-up or cool-down
  • Excessive up-hill and down-hill running
  • Positioning the feet “toed-in” to an excessive angle when cycling
  • Running up and down stairs
  • Hiking long distances, Rowing, Breaststroke, Treading water, Water polo
52
Q

Examples of abnormalities in leg/feet anatomy that contributes to IT band syndrome?

A
  • High or low arches (supination or pronation)
  • Excessive lower-leg rotation
  • Excessive foot-strike force
  • Uneven leg lengths
  • Bowlegs or tightness about the iliotibial band
53
Q

Examples of muscle imbalance contributing to IT Band syndrome.

A

o Weak hip abductor muscles

o Tight gluteus maximus and TFL

o Weak/non-firing multifidus muscle

o Uneven left-right stretching of the band, which could be caused by habits such as sitting cross-legged

54
Q

What sinew channel would we look at for IT Band syndrome?

A

Gallbladder

55
Q

What is Osgood Schlatter’s disease?

A

Inflammation of the patellar ligament at the tibial tuberosity with possible incomplete avulsion of tibial tuberosity

56
Q

What are causes of OSD?

A
  • Overuse (especially in sports involving running, jumping and quick changes of movement)
  • Adolescent growth spurts
57
Q

What are symptoms of Osgood Schlatter’s disease?

A
  • Pain in the front lower part of the knee around the tibial tuberosity
  • Pain is initially mild and intermittent in the acute phase. Pain will become more severe and continuous in nature as it progresses
  • Pain occurs during activities such as running, jumping, squatting, and especially ascending or descending stairs and during kneeling.
58
Q

What are the risk factors of OSD?

A
  • Male
  • Male to female ratio is ranging from 3:1 to 7:1
59
Q
A

Orthopedic Diagnostics (10 decks)

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