knee presentations Flashcards
Patellar fx epidemiology
1% of all fxs
most common 20-50 yo
Males 2x>F
>50% non-displaced
Patellar fx hx
MOI: fall on A. knee
sudden quad activation
Patellar fx sxs
pain/inability to extend knee
A. knee pain
Patellar fx exam
-palpable gap at fx site (may or not)
-local tenderness
-painful RT> AROM for ext
-painful end range flex ROM
-antalgic gait
Pittsburgh knee decision rule
- hx blunt trauma/fall
- inability to WB x4 steps immediately and in ED
- age <12 y/o OR >50
Ottawa knee decision rule
TTP head of fibula
inability to WB x4 steps immediately or in ED
Age >/= 55
inability to flex knee 90
isolated TTP patella
Tendon rupture: patellar and quad epidemiology
patellar: <40 yo commonly
quad: >40 yo commonly
quad: M 4-8x>F
Patellar and quad tendon rupture rfs
-local steroid injection
-prolonged corticosteroid use
-RA
-lupus
-connective tissue diseases
-infectious diseases
-arteriosclerosis
-DM
-hyperthyroidism
Patellar and quad tendon rupture hx
-eccentric overload extensor mechanism/trauma
-sudden onset from fall, hemarthrosis common
—-quad: related to regaining balance/rapid quad contraction
—-patellar: jump landing common
-hx degen. tendinopathy
-hx TKA
-ACL reconstruction (patellar tendon graft)
Patellar and quad tendon rupture sxs
anterior knee pain
Tendon rupture exam
-absent active knee ext OR painful active knee ext (complete/ partial)
-painful knee flexion ROM
-palpable defect
-antalgic gait OR unable to ambulate
Osgood Schlatter disease
apophysitis of tibial tubercle
M>F
ages: M: 10-15, F: 8-13
repetitive loading of knee into flexion
radiology: calcification of tibial tubercle
Osgood Schlatter hx
adolescent athlete
common bilaterally
Osgood Schlatter sxs
anterior knee pain
aggravated w/ activity/ resisted knee ext
Osgood Schlatter exam
-local TTP
-prominent tibial tubercle observed visually
-pain end-range knee flex ROM
-painful RT w/ knee ext>AROM
-possibly pain w/ tuning fork
Articular cartilage deficits
lesion prevalence: 60-70%
32-58% non-contact trauma MOI
Articular cartilage healing
Loss of proteoglycans: matrix reaches loss that is irreversible (matrix cannot replenish)
Mechanical: blunt trauma, penetrating injury, friction abrasion, sharp concentration of joint forces
-Healing depends on extent: chondral, chondral/subchondral, subchondral, cystic
Articular cartilage healing: Chondral vs subchondral
Chondral: limited response bc no inflammatory response
Subchondral: extends to blood supply, fills in w/ fibrocartilage, fibrin clot at 48hrs, 2 months kinda looks like normal cartilage, erosive changes at 6 months
Osteochondritis Dissecans
-articular cartilage defect
-separation of cartilage from subchondral bone
-juveniles
Osteochondritis dissecans rfs
lateral aspect of medial condyle most common
-M>W
greatest 10-20 yo
active individuals
commonly bilat
Osteochondritis dissecans hx
-traumatic MOI vs insidious
-hemarthrosis w/in 2 hrs
Osteochondritis dissecans sxs
non-specific knee pain
aggravated w/ activity, improves w/ rest
stiff/swell with activities
grinding, locking, catching
Osteochondritis dissecans exam
TTP femoral condyle/ medial or lateral joint lines
antalgic gait
knee effusion
limited/ painful knee ROM
Articular cartilage defects -surgery interventions
-arthroscopic lavage and debride
-microfracture
-autologous osteochondral mosaicplasty grafting
-ACI (implant)
-OAT procedure (autograft transfer)
-Allograft transplantation
-post op mx
Meniscus lesion epidemiology
-incidence
-concomitant ACL injury common
Meniscus lesion hx
-contact vs noncontact injury vs degenerative
-audible pop in directional change
-delayed effusion (6-24 hrs following injury)
meniscus lesion sx
catching/ locking/ giving way
local knee pain
meniscus lesion exam
-pain at end range knee EXT
-pain/limited flex ROM
-pain/weak flex and ext RT
-joint line tenderness
+McMurray’s, Thessaly, Appley’s, dynamic test (lateral meniscus)
Varus or valgus test (not for meniscus but may be +)
Tissue healing: Ligament
1st degree: minor tear of fibers
2nd: partial tear of structure
3rd: complete rupture
Ligament heal P1
acute inflammation and reaction (3 days) hematoma formation
Ligament P2
repair and regeneration (2-3 days post injury to ~6 wks)
fibroblasts produce collagen
matrix disorganized
Ligament P3
remodeling and maturation (>=12mnths post injury)
collagen fibers more parallel
increase tissue concentration and tensile strength
Ligament healing requirements
-disrupted tissue must remain in continuity
-controlled forces necessary to facilitate collagen synthesis
-protection from harmful stresses on tissues
ACL lesion epidemiology
VERY common
knee OA incidence high following ACL injury
increase risk for injury to other stabilizers of knee
ACL lesion correlations
-Females 2-9x>M
(jump landing mechanics, Q angle, narrower intercondylar notch, hormones and laxity)
-decreased hamstring or core strength
-duration of activity/fatigue
-dry/artificial turf
-high BMI
ACL lesion hx
-non contact injury (more likely)
pivoting w. planted foot and ext knee
deceleration and direction change/ cutting
jump landing in full knee ext
hyperext or hyperflex of knee
-contact injury
varus or valgus force to knee that imposes shear force on joint
ACL lesion sxs
-feeling of instability in knee
-c/o severe pain at time of injury
-audible pop w/ injury
-report of immediate swelling immediately (effusion)
ACL lesion exam
-weigh shifted posture when standing
-knee joint effusion
-antalgic gait
-AROM and PROM painful/limited all planes
-boggy/guarded end feel
-resisted testing weak and painful all planes
-excessive laxity w/ KT-1000 test
+pivot shift. anterior drawer, Lachman’s
PCL sprain epidemiology and hx
3-20% of knee injuries (not as common)
-audible pop
-MOI: posterior force at prox anterior tib
violent hyperext
fall on flexed knee w/ PF
PCL sprain sxs
local posterior knee pain aggravated w/ deceleration and kneeling
feelings of LE giving way/ instability
PCL sprain exam
gait: limited knee ext in stance
effusion
+posterior drawer
limited/painful knee ext and flex ROM
pain w/ RT of ext >90
MCL sprain epi
pretty common
correlation w/ soccer, football, hockey
high grade injuries may lead to chronic knee instability
common concomitant knee injuries
MCL sparin hx
MOI: valgus force, rotary trauma, younger>older, M 2x>F
MCL sprain sxs
medial knee pain
aggravated w/ activity, change in direction w/ ambulation, valgus force ay knee
MCL sprain exam
swell/bruise
antalgic gait
potential limited/painful knee ROM
local TTP
+valgus stress test
LCL sprain hx
MOI: varus trauma at knee
LCL sprain sxs
lateral knee pain
aggravated w. directional change in ambulation
LCL sprain exam
local lateral knee effusion
TTP LCL
+varus stress test ay 0 and 30 knee flex
guarded/boggy end feel w/ end range ROM flex and ext
Patellofemoral Instability predisposition
-structural: smaller patella, shallow groove (lateral tilt and lateral displacement toward ext (30)
-patella alta/baja
-quad muscle imbalance proposed (VMO/VL)
-generalized ligamentous laxity
Patellofemoral instability concerns
concern w/ tracking patella and distribution of loading
subsequent dislocations common
concomitant osteochondral lesion common
Patellofemoral instability hx
sublux/ dislocation of PTF joint
PTTF instability sxs
giving way of LE
peri-patellar pain
PTF instability exam
peripatellar tenderness
hypermobility
apprehension sign
ecchymosis/swelling/effusion in acute stage
recurrent instability= sx mx
PFPS correlations
-common w/ active individuals and adolescents
-altered patellar tracking contributes to aberrant loading patterns of joint
-quad weak/ muscle imbalance
-lateral retinaculum tightness
-increased Q-angle
-hip weakness (ABD, ER)
-altered foot/ankle kinematics
-increased femoral angle of inclination
-increased femoral anteversion
-limited hip extensor endurance
-VMO weakness
-Hip ER and ABD weak
-subtalar pronation (IR tibia)
PFPS hx
athletes
females
insidious
Osteoarthropathy
Knee is most common
Commonly symptomatic, hx of knee injury, obese people
Radiography: joint space loss, osteophytes, sclerosis
-symp vs asymp: joint pain and func limitation
PFPS sxs
-anterior/peri patellar knee pain
-aggravated w/ prolonged sitting, stairs, inclined walking, squatting
-knee crepitus
-catching at knee
PFPS exam
-patella alta/baja
-abnorm Q-angle
-pain squat
-possible peri-patellar swelling
-antalgic gait
-pain/limited knee flex/ext AROM
-pain/limit knee flex PROM
-pain/weak knee ext
-hip ER and ABD weakness
-pain/ hyper vs hypomobility PF joint
-+clarke’s
OA hx
-insidious
-hx trauma, sx
-family hx
-obesity
-knee hypermobility
-joint shape abnorm
-extreme physcial activity levels
->50 yo
-F>M
OA sxs
retropatellar pain
aggravated w/b activities, squat, stairs, prolonged sitting
crepitus
OA exam
-antalgic
-swelling/warm at knee
-TTP joint lines
-pain/limit knee ROM
-pain/limit knee RT
-maybe + Appley compression test
Arthrofibrosis
what is it?
-dense proliferative intra and extra-articular scar tissue formation w/ limitations in knee ROM
-inflammation present
-can lead to degenerative joint changes
Arthrofibrosis hx
traumatic injury/ sx
progressive increase in pain and knee ROM limits
Arthrofibrosis sxs
stiffness (worse in morning)
knee swelling
crepitus
diffuse knee pain
Arthrofibrosis exam
-limited knee ext in static stance or stance gait
-limit/pain knee ROM (PROM=firm end feel)
-hypomobile patellofemoral
-knee effusion/swelling
-inhibited/weak/pain knee ext
Genu recurvatum
what is it?
epidemiology
hyperext of knee >10 degrees
F>M
correlated w/ joint laxity, hx knee injury, poor muscular control (CVA)
excess stress on posterior knee structures
GR may predispose to
-ACL injury
-compressive injury anteriomedial tibiofemoral joint
-tensile loading posteriolateral joint supporters
-posterior corner capsulo-ligametous avulsion injuries
GR hx
-forced knee ext injury
-jump landing in ext
-force to anteriomedial prox tibia
-noncontact hyperext w/ planted foot
-concomitant PCL injury
GR sxs
c/o knee instability
anteriomedial knee pain or posteriolateral knee pain
GR exam
-postural exam- visually see hyperext (tibial ER, genu varum/valgum, tibial varum, excess pronation) (impaired proprio)
-edema, ecchymosis
-TTP locally
-NV screen necessary
-antalgic
-hypermobility P. glide w/ posteriolateral bias
Patellar Tendinopathy
Jumper’s knee
eccentric overload
microtrauma (failed healing response)
avg. 32 mnths pain/limitations
lot’s of athletes quit
PT hx
BB and volleyball players
PT sxs
anterior knee pain
aggravated w/ jumping/ extensor mechanism
PT exam
TTP patellar tendon/ inferior pole of patella
pain squat
pain end range flex ROM
pain RT>AROM knee ext
ITB friction syndrome
Knee: increased compression on soft tissues between lateral femoral condyle and ITB (~30 knee flex)
thickening of bursa
correlations: prominent femoral epicondyle, LLD
ITB FS hx
long distance runners
downhill skiers, jumping sports, weight lifters, cycling
insidious/progressive
ITBFS sxs
lateral knee pain
aggravated w/ activity/ repetitive knee flex/ ext and stairs
ITBFS exam
local TTP (distal ITB, gerdy’s, lateral femoral condyle)
+Ober
Hip ROM painful end range ADD
Potentially painful hip ABD RT
Baker’s Cyst
swelling at P. knee’
painful w/ synovial effusion
may rupture
Baker’s cyst hx
Intra-articular effusion
Baker’s cyst sxs
posterior knee pain
Baker’s cyst exam
-local swelling prox to popliteal fossa
-pain knee flex/ext ROM
-prominence of cyst increases w/ resisted knee flex
Bursitis: Knee
-superficial and deep infrapatellar (nun’s knee) (direct mechanical irritation)
-prepatellar (recurrent A. knee trauma)
-superficial Pes anserine (structures between MCL/pes)(swimmers/distance runners)
Bursitis knee exam
Local TTP
local swelling
Superficial Fibular Nerve (SFN) potential areas of compression
Trauma posteriolateral knee, compartment syndrome
SFN motor distr
fibularis longus and brevis
SFN sensory distr
distal 2/3 lateral leg/ankle/dorsal foot
SFN clin indics
-hx direct trauma/ iatrogenic
-neurodynamic tension test, sensitized w/ supination
