KNEE- Clinical Assessment Flashcards
What are the 4 main bursae likely to be inflammed in the knee
- Prepatella bursitis
- Infrapatella bursitis (superficial and deep)
- Pes anserine bursitis
- Suprapatellar bursitis
What isometric actions might you carry out to assess the knee
- Quadriceps
- Hamstrings
- Assess in varying lengths (muscle ranges)
What are the 5 stages of the Oxford Scale
- 0- No activity
- 1-Flicker of muscle activity
- 2-Full range with gravity eliminated
- 3-Full range against gravity
- 4- Full range against gravity and external resistance
- 5- normal power, R=L
Suggest 3 considerations to take into account if you believe the presenting complaint may be a bone fracture
- Mechanism of Injury – Trauma or overuse (tibial stress fracture) or fragility fracture of proximal femur.
- Age
- PMH – Osteoporosis, relative energy deficiency (REDS), long-term steriod use, Cancer
- Localised Pain worse on weight-bearing relieved when weight taken off. Limp.
- Osteosarcoma- child/young people, Constant pain, worse at night. Most common site is distal femur followed by proximal tibia.
During clinical examination, what might lead to you suspect an injury to the ACL
- Majority non-contact- knee externally rotated (10-30 degrees) then goes into varus and internal rotation e.g. in side-stepping or cutting movements.
- •Immediate swelling
- •Reduced movement especially inability to fully extend
- •Giving way on twisting movements
What’s most likely to cause Pes anserine bursitis
Sports that require repetitive use of S, G and ST e.g. running, cycling, breaststroke swimming and sports that require change of direction.
What are you looking to observe on clincal examination for suspected pes anserine bursitis
Palpation- local tenderness & Bursae- swelling +/- heat.
Observation – wide Q angle, knee valgus
Functional task – single leg squat, step up noting excessive valgus strain
For pes anserine and plica syndrome: Pain on repetitive active knee flexion and extension
Give three additional special questions you’d ask during a clinical examination of the knee
- Does your knee ever lock in a position that you can not move it? Yes/No
- Explain to me what happened to your knee the last time it happened. (?True locking)
- How often does this happen?
- Does you knee ever give way on you? (Yes/N0) Do you to fall on the floor? (Yes/No)
- Explain to me what happened to your knee the last time it happened (?True giving way)
- Swelling
What would the ideal examination look like to determine if there is a fracture present
- Palpation
- Observation and Functional task e.g. gait.
- Active range of motion
- (& Imaging i.e. Xray or MRI)
What would you palpate in the knee during clinical examination
- Skin- temperature, swelling, allodynia
- MCL/ LCL
- Joint line (meniscus)
- Patella (+ prepatellar, suprapatellar and infrapatellar bursa)
- Tibial tuberosity/ patella tendon
- Ischial tuberosity (hamstring tendons)
- Pes anserine/bursa (medial tibia, below joint line, at level of Tibial tuberosity)
- Plica (medial to paella over femoral condyle)
- Pulses – Popliteal, Posterior Tibial (between medial malleolus and TA), Dorsalis Pedis (lat to EHL distal to navicular)
During patient interview, what could suggest osgood schlatters disease as the diagnosis
- Age – Childhood
- Sporty children who complain of pain after sport.
- Develop a characteristic lump over tibial tuberosity
- Localised Pain and swelling
- Pain on isometric Quads
What would you assess for passive range of motion during clinical examination of the knee
Flex, Ext, Medial Rotation, Lateral Rotation
•Include over pressures and ‘END FEELS’ i.e. spongy or hard
What are the two special tests for the Upper Motor Nerves
- Babinski
- Clonus
What do the NICE guidlines suggest if you are concerned the diganosis may be RA
Treatment: Refer for specialist opinion any adult with suspected persistent synovitis of undetermined cause.
During observation (of the knee) what might you assess when standing
–Degree of valgus and varus
–Q-angle (ASIS to mid patella then patella tendon, normal 15-20 degrees)
–Leg length (skin creases, iliac crest)
–Patella size and position (alta-small, baja- low)
–Hyperextension of knee
–Whole kinetic chain
What are you looking to observe on clincal examination for suspected infrapatellar bursitis/ patella tendonitis-
Palpation- local tenderness, & Bursae- swelling +/- heat.
Isometric Quads – reproducing pain.
What is Plica syndrome
Irritation of the fold of synovial membrane (plica)
- Anteromedial knee pain - esp medial femoral condyle.
- Visible and palpably tender plica.
- Audible clicking or snap during knee motion - painful arc 30 to 60 degrees
- Positive Duvet test: pain eased by using a duvet between your knees to ease the pain in bed
Pathological features of osteoarthritis (OA)
–Bony sclerosis and eburnation (thickening)
–Osteophyte (bony spur) development at joint margins
–Softening of articular cartilage,
–Irregular thinning/ loss of cartilage,
–Fissures (long, narrow opening, crack) in cartilage expose underlying bone
- Pain
- Stiffness. Joint stiffness might be most noticeable upon awakening or after being inactive.
- Tenderness
- Loss of flexibility
- Grating sensation
- Swelling.
What do the Posterior draw and Posterior sag sign special tests highlight
PCL stability
What is the most likely mechanism to indicate meniscal injury
Rotational Forces in a flexed knee
In a patient interview, what could suggest osteoarthritis as the diagnosis
- Gradual onset (may have trauma)
- >45-years or over
- Joint pain related to activity and weightbearing
- Mild swelling
- Crepitus
- No early morning stiffness (EMS) or morning stiffness that lasts no longer than 30-minutes
- Exclusion of other diagnosis including gout, RA, septic arthritis and malignancy
- Observation – mild effusion, joint deformity (later stages)
What are the 3 special tests which asses meniscal integrity
- •McMurry’s
- •Apley’s
- •Thessaly test
During clinical examination, what would you be looking for if you suspected muscle injury or tendonitis
- Strains – Hamstrings, Gastrocnemius, Quadriceps
- Tendonitis- Patella tendonitis
- Mechanism of injury – sudden (strain) versus gradual onset (tendonitis).
- Muscle testing – contractile tissue
- Palpation – show me where you pain is?
- Pain on passive movement in opposite direction.
In a patient interview, what could suggest rheumatoid arthritis as the diagnosis
- Early morning stiffness (EMS) for longer than 30minutes.
- Swelling and heat
- General health: may have malaise (feeling unwell), fatigue and low grade fever as systemic.
- Extra-articular- rheumatoid nodules, vasculitis, pulmonary fibrosis, carditis, ocular disease
During clinical examination, what might suggest DVT as the diagnosis
- Swelling and redness
- Past Medical History of smoking, diabetes, obesity, high blood pressure.
- Leg pain (cramping) when walking (claudication) relieved with rest.
- Discolouration, swelling, shiny skin, sores that won’t heel.
- Temperature difference
- Loss of pulses – Posterior Tibial (between medial malleolus and TA), Dorsalis Pedis (lat to EHL distal to navicular)
- Recent history of travelling i.e. plane
What’s most likely to cause infrapatella bursitis (superficial and deep)
“jumpers knee” repetitive strain and irritation to patella tendon often due to jumping activities.
What would you asses for active range of motion in the knee
•Patient in Supine
–Flex, Ext,
•Patient sitting on edge of bed
–Extension
–Medial and lateral with knee at 90*
–Check PFJ tracking
What’s most likely to cause prepatella bursitis
”Housemaids knee” carpet layers, gardeners, roofers and plumbers.
- pressure from constant kneeling
- a direct blow to the front of knee can also cause prepatellar bursitis
What’s most likely to cause Suprapatellar bursitis
blunt trauma e.g. fall onto knee and repetitive overuse e.g. running.
Describe characteristics of an acute meniscal tear
- Non-contact: sudden twisting
- Contact- Foot planted, Varus force on flexed knee with femur ext rotated- lat. Meniscus. Valgus force, femur int. rotated, medial meniscus
- •Localised pain on joint line
- •Localised swelling
- •Locking
Describe characteristics of a degenerative meniscal injury
- Gradual onset
- Pain difficult to pin-point.
- Recurrent swelling
What do the Varus and Valgus strain special tests identify
MCL/LCL ligament stability
What do the Lachmans and anterior draw test
ACL stability
When assessing the lower motor nerves, what would you test in a clinical examination
Neurology exam -Motor, sensory and reflex responses.
What do the following special tests assess
- McMurry’s
- Apley’s
- Thessaly test
the meniscus
Pathological features of rheumatoid arthritis (RA)
–Invasion and erosion of underlying bone
–Destruction of cartilage
- Fatigue.
- Joint pain.
- Joint tenderness.
- Joint swelling.
- Joint redness.
- Joint warmth.
- Joint stiffness.
- Loss of joint range of motion
During clinical examination, what types of features suggest a neurological pathology
- •Pins and needles/ numbness
- •Problems with bladder/bowel
- •Pareathesia in the groin
- •Night pain
- Pain – burning
- Weakness
If the mechanism was a direct blow to anterior tibia, which ligament is most likely to be affected
PCL
State 4 examples of functional movements you might assess for the knee
- Activity that reproduces symptoms
- Gait
- Sit-stand
- Lunge
- Hopping
- Full Squat
- Single leg stand (eyes open and eyes closed)
- Single leg squat
