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musculo > Knee Complex: Patient Examination > Flashcards

Knee Complex: Patient Examination Flashcards

1
Q

what are some questions we are thinking of when we ask the patient “tell me about what is going on with your knee?”

A

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

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2
Q

what are some additional questions to ask a patient?

A

what type of footwear do you usually use?
when is the last time you replaced your footwear?

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3
Q

what are some observational things we look for?

A

edema/effusion, bruising, scarring, color, deformity, posture, surgery (scars)

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4
Q

if there is a lot of swelling in the fist 0min-2hours what could it be caused from?

A

hemarthrosis (potentially ACL, PCL, fracture, articular defect)

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5
Q

if there is a lot of swelling in the fist 6-24 hours what could it be caused from?

A

synovial origin (potentially meniscal tear)

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6
Q

what are we observing in the anterior view?

A

genu varum/valgum
patella position- facing in/out?, rotated?, tilted?
limb symmetry

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7
Q

what are we observing in the lateral view?

A

genu recurvatum
patella position- alta (camel sign), baja
osgood schlatters

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8
Q

what are we observing in terms of gait assessment?

A

stride length
walking speed
cadence
linear or angular displacement

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9
Q

what do we do in a lower quarter screen?

A

AROM
AROM with passive OP
screen for fracture
dermatomal testing
myotomal testing
MSRs
heel/toe walk

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10
Q

what movements are we testing with AROM?

A

flexion/extension (2 joint muscle consideration)

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11
Q

what are we looking for with PROM?

A

end feel:
extension -> firm to hard
flexion -> soft
rotation -> firm

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12
Q

give some examples of documentation of AROM/PROM

A

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

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13
Q

for flexion in open chain what direction are the roll and slide?

A

its concave on convex so posterior roll posterior slide

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14
Q

for extension in open chain what direction are the roll and slide?

A

concave on convex so anterior roll anterior slide

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15
Q

for flexion in closed chain what direction are the roll and slide?

A

convex on concave so posterior roll anterior slide

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16
Q

for extension in closed chain what direction are the roll and slide?

A

convex on concave so anterior roll posterior slide

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17
Q

for joint play at the knee for flexion in open chain where do we stabilize?

A

femur

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18
Q

for joint play at the knee for flexion in open chain where do we mobilize?

A

tibia

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19
Q

for joint play at the knee for flexion in open chain what is the direction of the glide?

A

posterior

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20
Q

for joint play at the knee for extension in open chain where do we stabilize?

A

femur

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21
Q

for joint play at the knee for extension in open chain where do we mobilize?

A

tibia

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22
Q

for joint play at the knee for extension in open chain what is the direction of the glide?

A

anterior

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23
Q

for joint play at the knee for flexion in closed chain where do we stabilize?

A

tibia

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24
Q

for joint play at the knee for flexion in closed chain where do we mobilize?

A

femur

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25
Q

for joint play at the knee for flexion in closed chain what is the direction of the glide?

A

anterior

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26
Q

for joint play at the knee for extension in closed chain where do we stabilize?

A

tibia

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27
Q

for joint play at the knee for extension in closed chain where do we mobilize?

A

femur

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28
Q

for joint play at the knee for extension in closed chain what is the direction of the glide?

A

posterior

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29
Q

at what degrees do we do break test or FTPO for the quadriceps?

A

0º, 30º, 60º, 90º

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30
Q

at what degrees do we do break test or FTPO for the hamstrings?

A

45º

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31
Q

what muscles do we do MMT for?

A

quadriceps and hamstrings (hip and foot looked at a lot too)

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32
Q

how can we do functional strength assessment of the quadriceps?

A

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)

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33
Q

what are some suggestions to avoid over grading?

A

1 rep max leg press
HHD

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34
Q

what are some functional testing of endurance?

A

6 min walk test
stair climb test
timed up and go

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35
Q

what is a functional and return to sport testing?

A

SEBT
Hop testing

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36
Q

how do we measure swelling?

A

circumferential or modified stroke test

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37
Q

what are some local causes of swelling?

A

overuse
repetitive microtrauma

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38
Q

what are some systemic causes of swelling?

A

monoarticular arthritis
infiltrative disorders (gout, pseudogout)
immunological diseases (reiter’s syndrome, RA, rheumatic fever)
cancer (most common joint to find benign and malignant tumors)

39
Q

what do we do special tests for?

A

meniscus (acute vs degenerative)
ligament (ACL, PCL, MCL, LCL)
patellofemoral (PFPS, patellar tendinopathy, dislocation)
hamstring strain
ITB friction syndrome

40
Q

what are some differential diagnosis for meniscus injury?

A

meniscus: ACL, MCL/LCL, PFPS
articular cartilage defect (degenerative): OA, loose body
other: lumbar radiculopathy, hip pathology

41
Q

what are some clinical findings for meniscus injuries?

A

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

42
Q

what are some clinical findings for articular cartilage injuries?

A

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

43
Q

what are the 5 symptoms in the meniscal composite score?

A

history of catching or locking
pain with hyperextension
pain with flexion
joint line tenderness
pain or click with McMurray

44
Q

if a patient reports 5 of the 5 symptoms in the meniscal composite score what is the specificity rate?

A

99%

45
Q

if a patient reports 4 of the 5 symptoms in the meniscal composite score what is the specificity rate?

A

96%

46
Q

if a patient reports 3 of the 5 symptoms in the meniscal composite score what is the specificity rate?

A

90%

47
Q

overall McMurray’s test is 55% Sn, 77% Sp, how is it for the lateral meniscus?

A

50% Sn, 77% Sp

48
Q

overall McMurray’s test is 55% Sn, 77% Sp, how is it for the medial meniscus?

A

21% Sn, 94% Sp

49
Q

how specific and sensitive is Thessaly’s test at 20º for the medial meniscus?

A

83% Sn, 76% Sp

50
Q

how specific and sensitive is Thessaly’s test at 20º for the lateral meniscus?

A

68% Sn, 97% Sp

51
Q

overall joint line tenderness is 76% Sn, 77% Sp, how is it for the medial meniscus?

A

59-89% Sn, 83-97% Sp

52
Q

overall joint line tenderness is 76% Sn, 77% Sp, how is it for the lateral meniscus?

A

67-92% Sn, 95-96% Sp

53
Q

what are the diagnostic tests for articular cartilage?

A

acute trauma with hemarthrosis
intermittent pain and swelling
insidious onset aggravated by repetitive impact
history of catching or locking
joint line tenderness

54
Q

what ligaments are commonly sprained or torn in the knee?

A

ACL, PCL, MCL, LCL

55
Q

what are some common clinical findings for knee ligament sprains?

A

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

56
Q

what are some differential diagnoses for ACL tears?

A

meniscal tear
osteochondral injury
tibial plateau fracture
patellar dislocation
PCL tear

57
Q

what diagnostic testing can we do to determine ACL tears?

A

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)

58
Q

what are some differential diagnoses for PCL tears?

A

meniscal tear
osteochondral injury
tibial plateau fracture
patellar dislocation
ACL tear

59
Q

what diagnostic testing can we do to determine PCL tears?

A

AROM/PROM (decreased knee extension)
posterior draw at 90º (90% Sn, 99% Sp)
posterior sag (79% Sn, 100% Sp)

60
Q

what are some differential diagnoses for MCL tears?

A

ACL/PCL tears
tibial plateau fracture
meniscal tear
osteochondral fracture

61
Q

what diagnostic testing can we do to determine MCL tears?

A

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

62
Q

what are some differential diagnoses for LCL tears?

A

ACL/PCL tears
tibial plateau fracture
meniscal tear
osteochondral fracture

63
Q

what diagnostic testing can we do to determine LCL tears?

A

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

64
Q

what are some differential diagnoses for PFPS?

A

patellar tendinopathy
patellar subluxation or dislocation
osgood-schlatter
sinding-larsen-johansson
plica syndrome

65
Q

how is PFPS diagnosed?

A

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

66
Q

what are the 4 patellofemoral pain cluster of findings?

A

overuse/overload without other impairment
PFP with movement coordination deficits
PFP with muscle performance deficits
PFP with mobility impairments

67
Q

how do we test for the overuse/overload without other impairment pain cluster of PFPS?

A

eccentric step down test
reproduction of anterior knee pain

68
Q

how do we test for PFP with movement coordination deficits pain cluster of PFPS?

A

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)

69
Q

how do we test for the PFP with muscle performance deficits pain cluster of PFPS?

A

hipSIT
hip muscle strength testing (isometric)
thigh strength testing (isometric)

70
Q

how do we test for the PFP with mobility impairments pain cluster of PFPS?

A

hypermobility: foot mobility testing
hypomobility: patellar tilt test of lateral patellar retinaculum, muscle length testing, hip IR and ER ROM testing

71
Q

what are some diagnostic tests for patellar dislocation?

A

AROM/PROM
joint play
PFJ apprehension test

72
Q

what are some differential diagnoses for patellar tendinopathy?

A

quadriceps tendinopathy
PFPS
ACL/PCL sprain/tear

73
Q

what diagnostic testing can we do for patellar tendinopathy?

A

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

74
Q

what is the patellar tendinopathy clinical decision guide?

A

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

75
Q

what are some differential diagnoses for hamstring strains?

A

lumbar radiculopathy
SI dysfunction
deep gluteal syndrome with nerve entrapment
adductor muscle strain

76
Q

what do we see in patient examination with a patient with a hamstring strain?

A

sudden onset of posterior thigh pain
reporduction of pain with hamstring strecthing and activation
muscle tenderness with palpation
loss of function
previous HSI

77
Q

what is a grade 1 hamstring strain?

A

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

78
Q

what is a grade 2 hamstring strain?

A

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

79
Q

what is a grade 3 hamstring strain?

A

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

80
Q

what is some diagnostic testing for hamstring strains?

A

active knee extension test (AKE)
HHD hamstring force
TTP distance from IT

81
Q

what are some special tests for ITB friction syndrome?

A

Ober’s test (hip)
nobel compression test

82
Q

what is ober’s test (hip) for ITB friction syndrome?

A

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

83
Q

what is the nobel compression test for ITB friction syndrome?

A

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

84
Q

what are some differential diagnoses for OA?

A

lumbar radiculopathy (disc derangement or lateral stenosis) L3-L4
meniscal tear (degenerative)
osteonecrosis of femur or tibia
septic arthritis
primary hip pathology

85
Q

what is the clinical prediction rule for OA?

A

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)

86
Q

what is the american college of rheumatology criteria for OA?

A

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

87
Q

what diagnostic testing is there for OA?

A

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

88
Q

what flexibility testing is there for the quadriceps?

A

Ely’s position

89
Q

what flexibility testing is there for the hamstrings?

A

SLR, HS 90/90 or AKE

90
Q

what flexibility testing is there for the hip?

A

thomas sign

91
Q

what is the neurodynamic testing for sciatic nerve?

A

SLR

92
Q

what is the neurodynamic testing for femoral nerve?

A

femoral slump

93
Q

what is the general neurodynamic testing?

A

slump test

94
Q

what do we palapte in the knee?

A

suprapatellar pouch
MCL, LCL
patellar ligament
patella
plica
infrapatellar bursa
tibial tuberosity
ITB
joint line
musculature

musculo (19 decks)

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