Knee, Foot, and Ankle Pain

Question 1

Inspection of the knee

Answer 1

check for swelling, deformity, symmetry, gait, etc

Question 2

Palpation of the knee

Answer 2

– Palpate bony and soft tissue
– Note any swelling, crepitus, warmth and/or
deformity
– Palpate the Patella, head of fibula, head of tibia, quadriceps femoris tendon, patellar ligament, patellofemoral compartment

Question 3

Range of Motion of the knee

Answer 3

– Hinge joint, primary motion (flexion, extension)

– Tibia movement in regards to the femur (internal and external rotation of the knee)

Question 4

Reflexes of the knee

Answer 4

patellar

Question 5

Strength of the knee

Answer 5

ROM against resistance

Question 6

Neurovascular of the knee

Answer 6

sensations

Question 7

Special tests of the knee

Answer 7

--Valgus stress test
– Varus stress test
– Lachmans
– Anterior draw
– Posterior draw
– Etc..

Question 8

Genu Varus

Answer 8

-“bow legs”
-causes: blount’s disease, rickets, skeletal dysplasia and asymmetric growth due to trauma, infection, neoplasia
-physiologic bowing decreases with age
=Pathologic bowing (obtain XR, orthopedic consult, consider referral)

Question 9

Genu Valgum

Answer 9

• “knock knees”
• increases femoral anterversion
• more common in females than males
• causes: intrauterine molding, genetic, cozen fracture, obesity
• may present with pain on the medial foot or knee

Question 10

ACL Tear/Injury

Answer 10

• More common in females
• Causes: noncontact sports
• Clinical presentation/ exam findings:
– injury with popping sounds with subsequent pain and swelling at the knee, feeling instability
Lachman test
– Specialty test: anterior drawer test and Lachman test sensitive
– MRI for imaging
• Late complication is development of OA in later life
• Treatment:
– Conservative management – RICE initially, Physical therapy
– Surgery

Question 11

PCL Tear/Injury

Answer 11

• Uncommon injury
• It is the largest and strongest of the knee ligaments
• Causes: usually occurs with combination with other bulk ligament injury due to trauma
• Clinical presentation/ exam findings:
• Setting of MVA with multiple structures involved, complete
dislocation of the knee
• Posterior draw test and positive sag sign
• Initial XR of knee to r/o fracture and later MRI
Sag sign
Image retrieved on 8/14/18 from Uptodate
• Late complication is development of OA in later life
• Treatment:
• RICE
• Hinge bracing, immobilizer
• PT
• Ortho referral

Question 12

MCL Injury

Answer 12

• Most common ligament injury
• Causes: Usually in athletes in sports that involve sudden change in direction (i.e. shoe catching on playing surface while player changes direction and speed in in sports dealing with contact or collision
• Clinical presentation/ exam findings: Pain and swelling of knee, laxity with valgus stress test
The valgus stress test (photo A) is used to assess the integrity of the medial collateral ligament, while the varus stress test is used to assess the lateral collateral
• Specialty test: Valgus stress test with knee at 0 and 30 degree flexion
ligament.
Uptodate
• Treatment: – RICE
– Physical therapy

Question 13

LCL Injury

Answer 13

• Least common injury
• Causes: Joint struck from the medal side (varus stress)
• Usually also has injury of the posterior lateral knee and other
structures including ACL, PCL and lateral meniscus
• Clinical presentation/ exam findings: blow to medial or anteromedial aspect of leg with resulting lateral or
Posterior draw test
Image retrieved on 8/14/18 from Uptodate
posterolateral knee pain. Presents with swelling, locking
and knee giving out under stress
• Specialty test:
• Varus stress test with leg at full extension and 30
degree
• Posterior drawer test
• Dial test
• Treatment:
• Low grade injury require physical therapy and crutches
• High grade injury require immobilization

Question 14

Meniscal Injury

Answer 14

• Common injury
• Causes: twisting injuries (sports related), chronic degenerative tears of the meniscus or the cartilage in older patients (mild twisting and stress on knee)
• Clinical presentation/ exam findings:
– Joint line tenderness, joint effusion/ swelling, catching, pain with certain movements, inability to squat/kneel
McMurray Testing
• Specialty testing:
– McMurray test
– Apley grind test
– Both test irritate the meniscus (cartilage) if injured
• Treatment: – RICE
– Crutches
– Physical therapy for chronic or acute cases
– Orthopedic referral for possible surgery

Question 15

Patellofemoral Pain

Answer 15

• Also known as retropatellar pain syndrome, runner’s knee, lateral facet compression syndrome, and idiopathic anterior knee pain
• Most common cause of knee pain seen in primary care
• Causes:
– Overuse disorder
– Biomechanical abnormalities ( eg length discrepancy, abnormal patellar movement, abnormal foot anatomy)
– Dynamic biomechanical abnormalities (muscle weakness or imbalance, foot pronation abnormality, hip weakness or adduction)
• Clinical presentation/ exam findings:
– anterior knee pain around or behind the patella
– Pain aggravated activity or weight bearing
• Specialty Testing
– Squatting (resulting in pain)
– Patellar glide (manually displacing patella with knee in extension)
• Treatment:
– Modify activity
– NSAID
– Physical therapy i.e. stretching, strengthen quadriceps muscle, strengthen hip)
– Steroids
– Fix biomechanical abnormality

Question 16

Osteoarthritis

Answer 16

• Can occur many large joints (hips, spine, ankle, shoulder), knee joint is one of the most commonly affected
• Degenerative (“wear and tear”) and inflammation
• Causes: Joint injury, Obesity, Aging, Anatomic (mutation of collagen type II, IX or XI), Gender (women>male)
• Clinical presentation/ exam findings:
– Joint pain, stiffness, restriction of motion
– Crepitus on flexion and extension of the knee
– May have swelling, deformity of affected joint or instability
– Pain worsens as day progresses
• Diagnosis based on clinical presentation, XR indicated only when diagnosis unclear
• Treatment:
– Weight bearing exercise, braces
– Acetaminophen or NSAID, topical capsaicin
– steroid injection
– Hyaluronic acid injection
– Joint replacement

Question 17

Osgood Schlatter

Answer 17

• “osteochondritis of tibial tubercle”
• Causes: caused by repetitive strain and tearing of the secondary ossification center on the tibial tubercle, over time it causes callous that appears as swelling of the tibial tubercle where the patellar tendon inserts
• Diagnosis based on history, no imaging needed, consider imaging with patient with other red flags along with anterior knee pain
• Treatment:
– Usually self limiting
– May take Acetaminophen and NSAID
– Physical therapy if quadriceps and hamstring muscle affected

Question 18

Ottawa Knee Rules

Answer 18

• Age 55 years or older
• Tenderness at head of fibula
• Isolated tenderness of patella
• Inability to flex knee to 90 degrees
• Inability to walk four weight-bearing steps immediately after the injury and in the emergency department

Question 19

Pittsburgh Decision Rules

Answer 19

• Blunt trauma or a fall as mechanism of injury plus either of the following:
• Age younger than 12 years or older than 50 years
• Inability to walk four weight-bearing steps in the emergency department

Question 20

Palpation of the Ankle

Answer 20

– Palpate anterior ankle joint
– Medial and lateral malleolus
– Achilles tendon
– Metatarsophalangeal joint
– Heel (calcaneus, plantar fascia)
– Metatarsal heads

Question 21

Ankle Reflexes

Answer 21

Achilles

Question 22

Special Ankle Tests

Answer 22

– Talar tilt test
– Eversion test
– Homan’s

Question 23

Testing for Diabetic Neuropathy

Answer 23

-Pressure sensation using Monofilament testing
• Vibration sensation using tuning fork
• Superficial pain using pinprick
-Note: a complete diabetic foot exam include pulses, checking for skin lesions (don’t forget to check between the toes)

Question 24

Ankle Sprain

Answer 24

• Acute ankle sprain is one of the most common reasons for visit to primary care office or ER
• Most commonly inversion injury for lateral ankle ligament is most common (tenderness over anterior talofibular and calcaneofibular ligament)
• Cause/risk factors: Can be due to sports or non-sport related, female> male, children and adolescent > adults
• Clinical presentation/ exam findings:
– Tenderness, swelling and ecchymosis of the ankle
– Mechanism of injury
– swelling, bruising and tenderness over the
• Specialty Testing:
– Anterior drawer
– Inversion stress/ talar tilt test
• Use Ottawa ankle rule to help decide if imaging needed to evaluate for fracture
• Treatment:
– RICE
– Bear weight as tolerated, No need to immobilize
– Splint or bracing
– NSAID
– Physical therapy

Question 25

Ottawa Ankle Foot Rules

Answer 25

• Ankle radiography is indicated only if patient has pain in the malleolar zone
• bone tenderness or the inability to bear weight

Question 26

Syndesmotic Ankle Injury

Answer 26

• high ankle sprain
• Injury to one or more of the ligaments including the distal tibiofibular syndesmosis
• Commonly in high intensity sports due to collision or contact sports such as football, soccer, etc
• Clinical presentation/ exam findings:
– Tenderness, swelling and ecchymosis of the ankle
– High impact mechanism of injury • Specialty Testing:
– Squeeze test – Compress fibula and tibia
• Obtain image, XR, MRI for definitive diagnosis
• Treatment:
– RICE
– May consider immobilize and then reexamining on followup
– Rehab
– Surgery

Question 27

Common Ankle Fractures

Answer 27

• Common injury usually from minor trauma.
• Young adult males and women 50-70 year age most commonly affected
• Causes/Risk factors: being athletic or elderly increases risk, inversion or eversion injury
• Inversion injuries typically cause stretching of the lateral ankle structures and compression of the medial structurestherefore lateral malleolus fracture
• Eversion injuries typically cause stretching of the medial ankle structures and compression of the lateral structures therefore medial malleolus fracture
• Clinical presentation:
– pain, swelling, deformity, skin abnormality (laceration, blistering, bruising, etc)
– Examiner should palate for area of tenderness and evaluate tibia, fibula and ligament
• Image using Xray AP and lateral views
• Treatment
– Non weight bearing
– Orthopedic consult
– cast or boot should hold the ankle at 90 degrees

Question 28

Metatarsal Fractures

Answer 28

•Causes/Risk factors: direct blow, twisting injuries, women with osteoporosis, diabetics •Clinical presentation:
Image using Xray AP and lateral views
Metatarsal Fractures
– pain, swelling, deformity
– Examiner should palate for area of tenderness
– Make sure to perform neurovascular exam
Treatment
– Non-weight bearing
– If Non-displaced fracture: Splint
– If displaced fracture: Cast

Question 29

Plantar Fasciitis

Answer 29

Common cause of heel pain in adults
• Most likely biomechanical overuse causing micro tears in the plantar fascia causing
degeneration of fibrous tissue or acute inflammation
• Causes: multifactorial but can include flat feet, high arch, prolonged walking or standing on hard surface, excessive training
• Clinical presentation/ exam findings:
– Plantar or calcaneal pain on walking or hard surfaces
– Pain with first steps in the morning or after period of inactivity
– Pain with passive dorsiflexion
• Treatment:
– Modify activity
– Orthotics, arch support
– Exercises
– Steroid injection
– Surgery for refractory cases

Question 30

Exercises for Treatment of Plantar Fasciitis

Answer 30

• ankle foot circles
• toe curls
• stretch the plantar fascia
• roll stretch
• tape support
• heel raise

Question 31

Morton Neuroma

Answer 31

Pain between the metatarsal heads from the plantar digital nerve, most commonly affecting the third web space
• Causes: chronic trauma or repeated stress due to tight fitting shoes, high heels
• Clinical presentation/ exam findings:
– Burning pain third metatarsal space most common that radiates to
toes especially with activities – Numbness of the toes
• Specialty Testing
– Mulder’s sign: clicking sensation when palpating the third
intermetatarsal space
• Treatment:
– Shoe inserts
– Wearing better fitting shoes
– Steroid injection

Question 32

Gout

Answer 32

Precipitation of monosodium urate crystals in a joint space
• Most commonly affects the first metatarsal but can affect the midtarsal joints, ankles, knees, fingers
• Risk factors: genetics, age, sex, diet, occasionally trauma, certain foods (red meat, seafood, alcohol-containing beverages, sodas and fruit juices)
• Clinical presentation:
– Swollen erythematous tender joint on exam
• Patient complain that even their bedsheet grazing their toe will cause extreme pain – Serum uric acid levels and joint fluid analysis can be used to diagnose
• Treatment
– NSAID first line treatment i.e. Indomethacin
– Colchicine
– Steroids
– Prevention
• Dietary modification • Allopurinol
• IL-1 inhibitor

Question 33

Overuse Tendon Injuries

Answer 33

• Pain with overuse of the tendon is tendinopathy
• Risk factors:
– Extrinsic factors: over use of the tendon, training errors, smoking, medication abuse, inappropriate footwear, chronic stress
– Intrinsic factors: patient age, leg length, and vascular supply • Clinical presentation
– Swelling, warmth, pain
– Squeeze test: test for Achilles tendon rupture (squeeze gastrocnemius muscle) • Treatment
– RICE
– Modify activity
– Stretching
– Exercises

Question 34

Hallux Rigidus

Answer 34

stiffness of the great toe, most often due to osteoarthritis

Question 35

Hallus Valgus

Answer 35

valgus malformation of great toe

Question 36

Plantar Warts

Answer 36

plantar warts most often due to HPV1

Question 37

Corns and Calluses

Answer 37

-caused by abnormal pressure over the skin and bony prominences from shoes or foot breakdown
– Corn are callus with hyperkeratotic core

Question 38

Metatarsal Pain

Answer 38

– Metatarsalgia - pain on plantar surface second and third metatarsal
– Morton Neuroma

Question 39

Tinea Pedis

Answer 39

• fungal infection of the foot
  – Dry, scaling skin, itching
  – Topical fungal creams i.e. Lamisil

Question 40

Onychomycosis

Answer 40

– fungal infection of the nail
-Thickened discolored nails
– Oral antifungal medications most effective