Knee Clinical Presentations Cont.

Question 1

CPG PFPS

Answer 1

1. A → use reproduction of retropatellar/peri-patellar pain during squat as diagnostic test for PFPS
2. B → make the diagnosis of PFPS using the 3 criteria of:
   
   • presence of retropatellar or peri-paterllar pain
   • reproduction of pain with squatting, stair climbing, prolonged sitting, or other functional activities loading PFJ in flexed position
   • exclusion of all other conditions
3. C → use of patellar tilt test in presence of hypomobility to support diagnosis

Question 2

Osteoarthropathy of knee epidemiology

Answer 2

1. Joint most commonly affected by OA
2. Murphy et al., 2008
   
   • lifetime risk of symptomatic knee OA = 44.7%
   • hx of knee injury increases lifetime risk to 56.8%
   • incidence increased to 2/3 among obese
3. Radiography
   
   • joint space loss
   • osteophytes
   • sclerosis

Question 3

Hx of Knee osteoarthropathy

Answer 3

1. Insidious onset
2. Hx of trauma/prior knee surgery
3. family hx
4. obesity
5. knee hypermobility
6. joint shape abnormality
7. extreme physical activity levels
8. age > 50 yrs
9. female

Question 4

symptomology of knee osteoarthropathy

Answer 4

1. retropatellar pain
2. aggravated by
   
   • w/b activities
   • squatting
   • stairs
   • prolonged sitting
3. crepitus

Question 5

physical exam findings for knee osteoarthropathy

Answer 5

1. antalgic gait
2. swelling/warmth at knee
3. TTP joint lines
4. painful/limited knee ROM (flexion, extension)
5. painful/limited MMT

Question 6

what is arthrofibrosis?

Answer 6

1. dense proliferative intra-articular and extra-articular scar tissue formation with related limitations in knee ROM
   
   • inflammation present
   • may lead to degenerative joint changes

Question 7

Hx for arthrofibrosis

Answer 7

1. traumatic injury/knee surgery
2. progressive increase in pain and knee ROM limitations

Question 8

symptomology for arthrofibrosis

Answer 8

1. stiffness (worse in morning)
2. knee swelling
3. creptius
4. diffuse knee pain

Question 9

physical exam findings for arthrofibrosis

Answer 9

1. limited knee ext in static stance or stance phases of gait
2. limited/painful knee ROM
   
   • PROM with firm end-feel
3. hypomobile patellofemoral glides (multi-directional)
4. knee effusion/swelling
5. inhibited/weak/painful knee ext

Question 10

what is genu recurvatum?

Answer 10

hyperextension of the knees (>10º)

Question 11

epidemiology of genu recurvatum

Answer 11

1. females > males
2. correlated with:
   
   • joint laxity
   • hx knee injury
   • poor muscular control (CVA)
3. excessive stress on posterior knee structures

Question 12

genu recurvatum may predispose someone to ______

Answer 12

1. ACL injury
2. compressive injury anteriomedial tibiofemoral joint
3. tensile loading posteriolateral joint supporters
4. posterior corner capsulo-ligamentous avulsion injuries

Question 13

Hx for genu recurvatum

Answer 13

1. forced knee extension injury
2. jump landing in extension
3. force to anteriomedial proximal tibia
4. noncontact hyperextension with planted foot
5. concomitant PCL injury

Question 14

symptomology of genu recurvatum

Answer 14

1. C/O knee instability
2. anteriomedial knee pain vs posteriolateral knee pain

Question 15

physical exam findings for genu recurvatum

Answer 15

1. postural exam (visual inspection) → knee hyperextension
   
   • tibial ER
   • genu varum/valgum
   • tibial varum
   • excessive pronatio n
   • impaired propioception at knee
2. edema, ecchymosis
3. TTP locally
4. Neurovascular screening, exam necessary
5. antalgic gait
6. hypermobility posterior glide with posteriolateral bias (with ER of tibia)

Question 16

Patellar Tendinopathy general info

Answer 16

1. aka Jumper’s knee
2. caused by an eccentric overload
3. microtrauma
   
   • failed healing response
4. average 32 months pain/functional limitations
5. 53% of affected athletes quit sport

Question 17

Hx for patellar tendinopathy

Answer 17

1. basketball and volleyball players

Question 18

symptomology of patellar tendinopathy

Answer 18

1. anterior knee pain
2. aggravated with jumping/extensor mechanism

Question 19

physical exam findings for patellar tendinopathy

Answer 19

1. TTP patellar tendon/inferior pole of patella
2. painful squat
3. pain end-range flexion ROM
4. pain resisted > active knee extension

Question 20

what is ITB Friction syndrome?

Answer 20

1. At the knee
   
   • increased compression on soft tissue structures between lateral femoral condyle and ITB
   • thickening of burase

Question 21

ITB friction syndrome correlates

Answer 21

1. prominent femoral epicondyle
2. leg length discrepancy

Question 22

ITB friction syndrome Hx

Answer 22

1. long distance runners
2. downhill skiers,
3. Jumping sports
4. weight lifters
5. cycling
6. Insidious/progressive onset

Question 23

Symptomology of ITB friction syndrome

Answer 23

1. lateral knee pain
2. aggravated with activity/repetitive knee flexion/extension and stairs

Question 24

physical exam findings for ITB friction syndrome

Answer 24

1. local TTP
   
   • distal ITB
   • Gerdy’s tubercle
   • lateral femoral condyle
2. (+) Ober test
3. Potentially painful hip ABD MMT

Question 25

what is Hoffa's syndrome?

Answer 25

1. hypertrophy/inflammation of infrapatellar fat pad 2. impingement between femoral condyles and tibial plateau (knee extension)

Question 26

Hx for Hoffa's syndrome

Answer 26

1. trauma vs repetitive extension microtrauma

Question 27

Hoffa's syndrome symptomology

Answer 27

1. anterior (infrapatellar) knee pain 2. aggravated by activities that require (repetitive) knee extension

Question 28

physical exam findings for Hoffa's syndrome

Answer 28

1. pain knee extension ROM 2. Local TTP * medial and lateral patellar tendon

Question 29

what is Plica Syndrome?

Answer 29

1. irritated suprapatellar, mediopatellar infrapatellar and lateral patellar plicae 2. Normal structures; inflammation and hypertrophy in pathologic situations * during development synovial folds compartmentalize the knee * typically resorbs during month 3-4 of embryonic development; plica remains if this does not occur

Question 30

suggested clinical diagnosis for plica syndrome

Answer 30

1. Supportive hx 2. failure with conservative management 3. arthroscopic observation of fibrotic plica with impingement in patellofemoral joint during knee flexion 4. no other likely diagnostic hypothesis (Dx of exclusion)

Question 31

epidemiology of Plica Syndrome

Answer 31

1. symptomatic → from very common to non-existent (controversial)

Question 32

Hx for plica syndrome

Answer 32

1. microtrauma 2. any age * greatest risk at adolescence 3. intial knee injury with secondary inflammation to plicae

Question 33

symptomology of plica syndrome

Answer 33

1. anterior knee pain 2. clicking/catching/locking/giving way 3. aggravated with * activity * prolonged standing and sitting * squatting

Question 34

physical exam findings for plica syndrome

Answer 34

1. hypertrophied plica without effusion 2. TTP (local) 3. painful knee flexion ROM * less pain with active extension 4. painless extension PROM (likely)

Question 35

what is a Baker's cyst?

Answer 35

swelling at posterior knee painful with synovial effusion may rupture

Question 36

Hx for Baker's cyst

Answer 36

1. intra-articular effusion

Question 37

Symptomology of Baker's cyst

Answer 37

1. posterior knee pain

Question 38

physical exam findings for Baker's cyst

Answer 38

1. local swelling proximal to popliteal fossa 2. pain knee flexion/extension ROM 3. prominence of cyst increases with resisted knee flexion

Question 39

List the types of bursitis possible at the knee

Answer 39

1. superficial and deep infrapatellar (nun's knee) * direct mechanical irritation 2. prepatellar * recurrent anterior knee trauma 3. superficial pes anserine * structures between MCL/pes anserine * swimmers/distance runners

Question 40

physical exam findings for bursitis at the knee

Answer 40

local TTP local swelling

Question 41

potential area for entrapment of the superficial fibular nerve

Answer 41

1. trauma posteriolateral knee (fibrosis) 2. compartment syndrome

Question 42

motor distribution of the superficial fibular nerve

Answer 42

1. fibularis longus and brevis

Question 43

sensory distribution of the superificial fibular nerve

Answer 43

1. distal 2/3 lateral leg/ankle/dorsal foot

Question 44

other clinical indicators for the superficial fibular nerve

Answer 44

1. hx direct trauma/iatrogenic 2. neurodynamic tension test, sensitized with supination