Knee, Foot, and Ankle Pain/Exam

Question 1

ACL injury/tear

Answer 1

Presentation: injury w/ popping sounds and pain/swelling at knee
Treatment: RICE, physical therapy, surgery

Question 2

PCL injury/tear

Answer 2

Presentation: setting of MVA w/ multiple structures involved, complete dislocation of knee
Treatment: RICE, hinge bracing, PT, ortho referral

Question 3

Medial Collateral L. injury

Answer 3

usually in sports w/ sudden movement changes
Presentation: pain and swelling of knee, laxity w/ valgus stress test
Treatment: RICE, physical therapy

Question 4

Lateral Collateral L. injury

Answer 4

Presentation: blow to medial or anteromedial aspect of leg; lateral knee pain, swelling, locking, and knee giving out under stress
Treatment: physical therapy and crutches; immobilization if high grade

Question 5

Meniscal injury

Answer 5

twisting injuries
Presentation: joint line tenderness, joint effusion/swelling, catching, pain w/ certain movements, inability to squat/kneel
Treatment: RICE, crutches, physical therapy, ortho referral

Question 6

Patellofemoral pain

Answer 6

aka runner’s knee
Presentation: anterior knee pain around or behind patella
Treatment: modified activity, NSAIDs, physical therapy, steroids

Question 7

Osteoarthritis

Answer 7

Presentation: joint pain, stiffness, restriction of motion, crepitus on flexion and extension of knee
Treatment: weight bearing exercise, braces, NSAIDs, steroids, hyaluronic acid injection

Question 8

Osgood schlatter

Answer 8

callous appears and swelling of tibial tubercle where patellar tendon inserts
Presentation: teenager c/o pain and swelling of anterior knee
Treatment: usually self limiting, NSAIDs, PT

Question 9

Ottawa knee rules

Answer 9

determines who gets radiograph of knee after trauma - sensitive rule
age 55 or older
tenderness at head of fibula
isolated tenderness of patella
inability to flex knee to 90
inability to walk 4 weight-bearing steps immediately after injury

Question 10

Pittsburgh decision rules

Answer 10

determines who gets radiograph after knee trauma - more specific when dealing with isolated knee injury
blunt trauma or fall as mechanism of injury plus younger than 12 or older than 50; inability to walk 4 weight-bearing steps in ED

Question 11

Q angle (knee)

Answer 11

normal = 15 degrees
difference measured by created straight line from ASIS to center of patella and another line through tibial tuberosity and center of patella

Question 12

Knee flexion

Answer 12

145-150 - biceps femoris, semimembranosis, semitendinosis, gracilis, grastrocnemius, plantaris, sartorius, popliteus

Question 13

Knee extension

Answer 13

0 - rectus femoris, vastus lateralis, vastus medialis, vastus intermedius

Question 14

Knee internal and external rotation

Answer 14

10

Question 15

Patella reflex

Answer 15

L4

Question 16

Achilles reflex

Answer 16

S1

Question 17

Anteromedial thigh dermatome

Answer 17

L1-L3

Question 18

patella dermatome

Answer 18

L4

Question 19

anterior leg and ankle and great toe dermatome

Answer 19

L5

Question 20

lateral leg and lateral phalanges dermatome

Answer 20

S1

Question 21

posterior thigh dermatome

Answer 21

S1-S4

Question 22

Valgus Test (knee)

Answer 22

knee flexed to 30; physician supports lower leg and places hand on lateral aspect of knee; apply medial force to proximal tibia while abducting lower leg

(+) = increased laxity or pain
Indicates: medial collateral L. injury

Question 23

Varus Test (knee)

Answer 23

knee flexed to 30; physician supports lower leg and places hand on medial aspect of knee; apply lateral force to proximal tibia while adducting lower leg

(+) = increased laxity or pain
Indicates: lateral collateral L. injury

Question 24

Anterior Drawer Test

Answer 24

knee flexed to 90; physician sits on pt’s foot and grasps proximal tibia w/ both hands; pull anteriorly

(+) = excessive translation
Indicates: ACL injury

Question 25

Lachman's Test

Answer 25

physician places hand on distal thigh above patella and other hand grasps proximal tibia; knee flexed 10-30 and tibia pulled anteriorly while other hand stabilizes thigh (+) = increased laxity Indicates: ACL injury (more sensitive)

Question 26

Posterior Drawer Test

Answer 26

knee flexed to 90; physician sits on pt's foot and grasps proximal tibia w/ both hands; pull posteriorly (+) = excessive translation Indicates: PCL injury

Question 27

Reverse Lachman's Test

Answer 27

physician places hand on distal thigh above patella and other hand grasps proximal tibia; knee flexed 10-30 and tibia pushed posteriorly while other hand stabilizes thigh (+) = increased laxity Indicates: PCL injury (more sensitive)

Question 28

McMurray's Test

Answer 28

hip and knee flexed with hands placed to control ankle and distal femur Medial meniscus = rotate tibia into external rotation and apply valgus stress Lateral meniscus = rotate tibia into internal rotation and apply varus stress (+) = pain or clicking during extension Indicates: possible medial or lateral meniscus tear

Question 29

Apley's Grind Test - compression

Answer 29

pt prone w/ knee flexed to 90; downward force placed on foot while rotating it internally and externally (+) = pain w/ rotation and/or compression Indicates: possible meniscal injury, collateral L. injury or both

Question 30

Apley's Grind Test - distraction

Answer 30

pt prone w/ knee flexed to 90; apply upward traction to leg while rotating it (traction reduces meniscal pressure but increases ligamentous strain) (+) = pain w/ distraction and rotation Indicates: possible collateral L. damage

Question 31

Patellar Laxity and Apprehension Tests

Answer 31

Laxity: one hand above and below joint; thumbs placed against medial side of patella and push laterally Apprehension Test: when testing laxity, ask pt if maneuver provokes discomfort or instability (+) = sense of apprehension or instability Indicates: possible previous patellar dislocation or instability

Question 32

Patellar Compression (Grind) Test

Answer 32

knee extended and provide compressive load to patella w/ one hand while moving patella medial and lateral (+) = pain w/ compression Indicates: possible inflammation, chondromalacia, or injury to patellofemoral articular surfaces

Question 33

Patella-Femoral Grinding Test

Answer 33

compress patella downward into trochlear groove and instruct pt to tighten quadriceps against resistance (+) = crepitus or pain Indication: roughness or articulating surfaces

Question 34

Patellar Glide Test

Answer 34

pt sitting or supine will slowly extend and flex knee while physician notes quality of motion (+) = palpable or audible crepitus, pain, or catching of patella Indicates: possible damage to articular surface

Question 35

Syndesmotic ankle injury

Answer 35

high ankle sprain - injury to one or more ligaments including distal tibiofibular syndesmosis Presentation: tenderness, swelling, and ecchymosis of ankle w/ high impact mechanism of injury Management: RICE, consider immobilization, rehab, surgery

Question 36

Morton Neuroma

Answer 36

pain between metatarsal heads from plantar digital N. Presentation: burning pain third metatarsal space most common that radiates to toes w/ activity Treatment: shoe inserts, wearing better fitting shoes, steroid injections

Question 37

Plantarflexion

Answer 37

55-65 - coupled motion of supination

Question 38

Dorsiflexion

Answer 38

15-20 - coupled motion of pronation

Question 39

Ankle inversion

Answer 39

20 - coupled motion of supination

Question 40

Ankle eversion

Answer 40

10-20 - coupled motion of pronation

Question 41

Anterior Drawer Test (ankle)

Answer 41

grasp posterior calcareous w/ one hand and distal tibia/fibula w/ other; provide anterior force on calcaneus while stabilizing distal tibia/fibula (+) = pain, no springing, excessive motion/laxity Indicates: ATF ligament injury (lateral ankle sprain)

Question 42

Talar Tilt Test

Answer 42

graps distal tibia/fibula and inferior calcaneous blocking motion of calcaneous on talus; invert talus (+) = laxity, increased ROM or pain Indicates: calcaneofibular L. injury (lateral ankle sprain)

Question 43

Eversion Test

Answer 43

grasp distal tibia/fibula and plantar surface of mid-foot; evert foot (+) = laxity, increased ROM or pain Indicates: deltoid L. injury (medial ankle sprain)

Question 44

Squeeze Test

Answer 44

wrap hands around leg proximal to ankle; squeeze 2-3 seconds and rapidly release (+) = pain at syndesmosis Indicates: syndesmosis pathology (high ankle sprain)

Question 45

Cross Leg Test

Answer 45

pt crosses ankle over opposite knee; apply pressure to affected leg (+) = pain at distal ankle Indicates: syndesmosis pathology (high ankle sprain)

Question 46

Thompson Test

Answer 46

pt prone w/ foot off table; squeeze pt's calf and observe plantar flexion (+) = absence of plantar flexion Indicates: Achilles tendon rupture

Question 47

Homan's Sign

Answer 47

dorsiflex pt's foot (+) = pain w/ dorsiflexion Indicates: DVT

Question 48

Moses Sign

Answer 48

pt's knee slightly flexed or extended, induce anterior compression on gastrocnemius into posterior aspect of tibia (+) = pain w/ anterior compression Indicates: DVT

Question 49

Ottawa Ankle Rules

Answer 49

ankle series indicated for pts w/ pain in malleolar zone and have bone tenderness at posterior edge or tip of lateral or medial malleolus or unable to bear weight immediately after injury (4 steps)

Question 50

Ottawa Foot Rules

Answer 50

foot series for pt's w/ pain in mid-foot zone and bone tenderness at base of 5th metatarsal or navicular or unable to bear weight immediately after injury (4 steps)