Knee Complex: Patient Examination Flashcards
what are some questions we are thinking of when we ask the patient “tell me about what is going on with your knee?”
MOI
location of complaint
behavior of symptoms
nature of symptoms
medications
PMH/PSH/family history
B/W/S since onset
activity limitations/participation restrictions
recreational and work activity
diagnostic imaging
previous intervention
what are some additional questions to ask a patient?
what type of footwear do you usually use?
when is the last time you replaced your footwear?
what are some observational things we look for?
edema/effusion, bruising, scarring, color, deformity, posture, surgery (scars)
if there is a lot of swelling in the fist 0min-2hours what could it be caused from?
hemarthrosis (potentially ACL, PCL, fracture, articular defect)
if there is a lot of swelling in the fist 6-24 hours what could it be caused from?
synovial origin (potentially meniscal tear)
what are we observing in the anterior view?
genu varum/valgum
patella position- facing in/out?, rotated?, tilted?
limb symmetry
what are we observing in the lateral view?
genu recurvatum
patella position- alta (camel sign), baja
osgood schlatters
what are we observing in terms of gait assessment?
stride length
walking speed
cadence
linear or angular displacement
what do we do in a lower quarter screen?
AROM
AROM with passive OP
screen for fracture
dermatomal testing
myotomal testing
MSRs
heel/toe walk
what movements are we testing with AROM?
flexion/extension (2 joint muscle consideration)
what are we looking for with PROM?
end feel:
extension -> firm to hard
flexion -> soft
rotation -> firm
give some examples of documentation of AROM/PROM
R knee flexion AROM 5-0-135º, pain at end range 3/10 on VAS
R knee flexion AROM 5-135º, pain free
R knee flexion PROM, 7-0-139º, soft end feel
L knee extension AROM 125-0-2º
for flexion in open chain what direction are the roll and slide?
its concave on convex so posterior roll posterior slide
for extension in open chain what direction are the roll and slide?
concave on convex so anterior roll anterior slide
for flexion in closed chain what direction are the roll and slide?
convex on concave so posterior roll anterior slide
for extension in closed chain what direction are the roll and slide?
convex on concave so anterior roll posterior slide
for joint play at the knee for flexion in open chain where do we stabilize?
femur
for joint play at the knee for flexion in open chain where do we mobilize?
tibia
for joint play at the knee for flexion in open chain what is the direction of the glide?
posterior
for joint play at the knee for extension in open chain where do we stabilize?
femur
for joint play at the knee for extension in open chain where do we mobilize?
tibia
for joint play at the knee for extension in open chain what is the direction of the glide?
anterior
for joint play at the knee for flexion in closed chain where do we stabilize?
tibia
for joint play at the knee for flexion in closed chain where do we mobilize?
femur
for joint play at the knee for flexion in closed chain what is the direction of the glide?
anterior
for joint play at the knee for extension in closed chain where do we stabilize?
tibia
for joint play at the knee for extension in closed chain where do we mobilize?
femur
for joint play at the knee for extension in closed chain what is the direction of the glide?
posterior
at what degrees do we do break test or FTPO for the quadriceps?
0º, 30º, 60º, 90º
at what degrees do we do break test or FTPO for the hamstrings?
45º
what muscles do we do MMT for?
quadriceps and hamstrings (hip and foot looked at a lot too)
how can we do functional strength assessment of the quadriceps?
30 second chair stand test (requires strength equal to 1/2 BW unassisted)
descending stairs (forces exerted during task are 3x BW, requires strength greater than a MMT can assess)
what are some suggestions to avoid over grading?
1 rep max leg press
HHD
what are some functional testing of endurance?
6 min walk test
stair climb test
timed up and go
what is a functional and return to sport testing?
SEBT
Hop testing
how do we measure swelling?
circumferential or modified stroke test
what are some local causes of swelling?
overuse
repetitive microtrauma
what are some systemic causes of swelling?
monoarticular arthritis
infiltrative disorders (gout, pseudogout)
immunological diseases (reiter’s syndrome, RA, rheumatic fever)
cancer (most common joint to find benign and malignant tumors)
what do we do special tests for?
meniscus (acute vs degenerative)
ligament (ACL, PCL, MCL, LCL)
patellofemoral (PFPS, patellar tendinopathy, dislocation)
hamstring strain
ITB friction syndrome
what are some differential diagnosis for meniscus injury?
meniscus: ACL, MCL/LCL, PFPS
articular cartilage defect (degenerative): OA, loose body
other: lumbar radiculopathy, hip pathology
what are some clinical findings for meniscus injuries?
twisting injury
tearing sensation at time of injury
delayed effusion (6-24 hours post injury)
history of “catching” or “locking”
pain with forced hyperextension
pain with maximum passive knee flexion
pain or audible click with McMurray’s maneuver
joint-line tenderness
discomfort or a sense of locking or catching in the nee over either the medial or lateral joint line during the Thessaly test when performed at 20º knee flexion
meniscal pathology composite score: the combination of history of “catching” or “locking” pain with forced hyperextension, pain with maximum passive knee flexion, and pain or audible click with mcMurray’s maneuver
what are some clinical findings for articular cartilage injuries?
acute trauma with hemarthrosis (0-2 hours) (associated with osteochondral fracture)
insidious onset aggravated by repetitive impact
intermittent pain and swelling
history of “catching” or “locking”
joint-line tenderness
what are the 5 symptoms in the meniscal composite score?
history of catching or locking
pain with hyperextension
pain with flexion
joint line tenderness
pain or click with McMurray
if a patient reports 5 of the 5 symptoms in the meniscal composite score what is the specificity rate?
99%
if a patient reports 4 of the 5 symptoms in the meniscal composite score what is the specificity rate?
96%
if a patient reports 3 of the 5 symptoms in the meniscal composite score what is the specificity rate?
90%
overall McMurray’s test is 55% Sn, 77% Sp, how is it for the lateral meniscus?
50% Sn, 77% Sp
overall McMurray’s test is 55% Sn, 77% Sp, how is it for the medial meniscus?
21% Sn, 94% Sp
how specific and sensitive is Thessaly’s test at 20º for the medial meniscus?
83% Sn, 76% Sp
how specific and sensitive is Thessaly’s test at 20º for the lateral meniscus?
68% Sn, 97% Sp
overall joint line tenderness is 76% Sn, 77% Sp, how is it for the medial meniscus?
59-89% Sn, 83-97% Sp
overall joint line tenderness is 76% Sn, 77% Sp, how is it for the lateral meniscus?
67-92% Sn, 95-96% Sp
what are the diagnostic tests for articular cartilage?
acute trauma with hemarthrosis
intermittent pain and swelling
insidious onset aggravated by repetitive impact
history of catching or locking
joint line tenderness
what ligaments are commonly sprained or torn in the knee?
ACL, PCL, MCL, LCL
what are some common clinical findings for knee ligament sprains?
symptom onset linked to precipitating trauma
deceleration, cutting, or valgus motion associated with injury
“pop” heard or felt at time of injury
hemarthrosis within 0-12 hours following injury
knee effusion present
sense of knee instability reported
excessive tibiofemoral laxity with (cruciate/collateral) ligament integrity tests
pain/symptoms with (cruciate/collateral) ligament integrity tests
lower-limb strength and coordination deficits
impaired single leg proprioception/balance
abnormal compensatory strategies observed during deceleration or cutting movements
what are some differential diagnoses for ACL tears?
meniscal tear
osteochondral injury
tibial plateau fracture
patellar dislocation
PCL tear
what diagnostic testing can we do to determine ACL tears?
modified stroke test
AROM/PROM: limited extension
muscle performance testing- quads/hamstrings
KT1000
Lachman test (85% Sn, 94% Sp)
pivot shift test (24% Sn, 98% Sp)
what are some differential diagnoses for PCL tears?
meniscal tear
osteochondral injury
tibial plateau fracture
patellar dislocation
ACL tear
what diagnostic testing can we do to determine PCL tears?
AROM/PROM (decreased knee extension)
posterior draw at 90º (90% Sn, 99% Sp)
posterior sag (79% Sn, 100% Sp)
what are some differential diagnoses for MCL tears?
ACL/PCL tears
tibial plateau fracture
meniscal tear
osteochondral fracture
what diagnostic testing can we do to determine MCL tears?
AROM/PROM (in isolation with WNL)
+ valgus stress test at 30º (produce medial knee pain 78% Sn, 67% Sp) (increased separation between femur and tibia (91% Sn, 49% Sp)
tenderness over MCL reproducing complaint
what are some differential diagnoses for LCL tears?
ACL/PCL tears
tibial plateau fracture
meniscal tear
osteochondral fracture
what diagnostic testing can we do to determine LCL tears?
AROM/PROM (in isolation with WNL)
Varus stress test at 30º and 0º (production of lateral knee pain) (increased separation between femur and tibia)
tenderness over LCL reproducing complaint
what are some differential diagnoses for PFPS?
patellar tendinopathy
patellar subluxation or dislocation
osgood-schlatter
sinding-larsen-johansson
plica syndrome
how is PFPS diagnosed?
retropatellar or peripatellar pain
reporduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position
positive patellar tilt test
exclusion of all other possible sources of anterior knee pain
what are the 4 patellofemoral pain cluster of findings?
overuse/overload without other impairment
PFP with movement coordination deficits
PFP with muscle performance deficits
PFP with mobility impairments
how do we test for the overuse/overload without other impairment pain cluster of PFPS?
eccentric step down test
reproduction of anterior knee pain
how do we test for PFP with movement coordination deficits pain cluster of PFPS?
dynamic valgus on lateral step down test ( >2 point score on quality of movement)
frontal plane valgus during single leg squat (>10º increase in FPPA)
how do we test for the PFP with muscle performance deficits pain cluster of PFPS?
hipSIT
hip muscle strength testing (isometric)
thigh strength testing (isometric)
how do we test for the PFP with mobility impairments pain cluster of PFPS?
hypermobility: foot mobility testing
hypomobility: patellar tilt test of lateral patellar retinaculum, muscle length testing, hip IR and ER ROM testing
what are some diagnostic tests for patellar dislocation?
AROM/PROM
joint play
PFJ apprehension test
what are some differential diagnoses for patellar tendinopathy?
quadriceps tendinopathy
PFPS
ACL/PCL sprain/tear
what diagnostic testing can we do for patellar tendinopathy?
VISA-P score ≤ 88
PROM- end range flexion
muscle performance testing- resisted knee extension
flexibility assessment- prone knee flexion (Ely’s)
+ single leg decline squat (SLDS)
+ pain reproduction with palpation or royal london hospital test
what is the patellar tendinopathy clinical decision guide?
if a pt has 3+ to the following then they do PT, if they have all 3 negative then they don’t do PT
VISA-P ≤ 88, +SLDS, +palpation
what are some differential diagnoses for hamstring strains?
lumbar radiculopathy
SI dysfunction
deep gluteal syndrome with nerve entrapment
adductor muscle strain
what do we see in patient examination with a patient with a hamstring strain?
sudden onset of posterior thigh pain
reporduction of pain with hamstring strecthing and activation
muscle tenderness with palpation
loss of function
previous HSI
what is a grade 1 hamstring strain?
microtearing of a few muscle fibers, local pain of smaller dimensions, tightness and possible cramping in the posterior thigh, slight pain with muscle stretching and/or activation, stiffness that may subside during activity but returns following activity, minimal strength loss, and less than a 15º deficit with the AKE test
what is a grade 2 hamstring strain?
moderate tearing of muscle fibers, but the muscle is still intact, local pain covering a larger area than in grade 1, greater pain with muscle stretch or activation, stiffness, weakness, and possible hemorrhaging and bruising, limited ability to walk, especially for 24-48 hours after the injury, a 16-25º deficit with the AKE test
what is a grade 3 hamstring strain?
patient referred to a physician. complete tear of the muscle, diffuse swelling and bleeding, possible palpable mass of muscle tissue at the tear site, extreme difficulty or inability to walk, and a 26-35º deficit with the AKE test
what is some diagnostic testing for hamstring strains?
active knee extension test (AKE)
HHD hamstring force
TTP distance from IT
what are some special tests for ITB friction syndrome?
Ober’s test (hip)
nobel compression test
what is ober’s test (hip) for ITB friction syndrome?
patient position: sidelying, hip and knee flexed
PT position: standing behind the patient
technique: PT extends and ABD upper leg passively then allow the leg to lower towards the table while stabilizing pelvis- perform with knee flexed and extended
+ result: leg remains ABD -> contracture is present
what is the nobel compression test for ITB friction syndrome?
patient position: supine with knee flexed to 90º and hip flexed
PT position: standing on test leg side
technique: PT applies pressure over lateral femoral condyle or 1-2 cm proximal. Pt extends knee while PT maintains pressure
+ result: at approximately 30º the pt complains of extreme pain over the lateral femoral condyle = ITB friction syndrome
what are some differential diagnoses for OA?
lumbar radiculopathy (disc derangement or lateral stenosis) L3-L4
meniscal tear (degenerative)
osteonecrosis of femur or tibia
septic arthritis
primary hip pathology
what is the clinical prediction rule for OA?
symptom criteria:
1. knee pain
2. morning stiffness for <30 minutes
3. functional limitations
signs criteria:
1. knee crepitus
2. knee restricted ROM
3. bony enlargements
(post test probability 99% if all 6 criteria are positive, radiological grading required)
what is the american college of rheumatology criteria for OA?
age ≥ 50 years
stiffness ≤ 30 minutes
crepitus
bony tenderness
bony enlargement
no palpable warmth
at least 3 criteria- 95% Sn, 69% Sp
at least 4 criteria- 84% Sn, 89% Sp
what diagnostic testing is there for OA?
observation- bony enlargement
ROM- capsular pattern (loss of flex > loss of ext), pain at end ranges
muscle performance- weakness, FTPO- b scales, decreased WB compared to uninvolved
balance- EO, EC
activity related pain- functional testing
questionnaires- QoL, depression, motivation to self manage
what flexibility testing is there for the quadriceps?
Ely’s position
what flexibility testing is there for the hamstrings?
SLR, HS 90/90 or AKE
what flexibility testing is there for the hip?
thomas sign
what is the neurodynamic testing for sciatic nerve?
SLR
what is the neurodynamic testing for femoral nerve?
femoral slump
what is the general neurodynamic testing?
slump test
what do we palapte in the knee?
suprapatellar pouch
MCL, LCL
patellar ligament
patella
plica
infrapatellar bursa
tibial tuberosity
ITB
joint line
musculature
