Lecture 11: Approach to Knee, Ankle, and Foot Complaint

Question 1

What do these sensations suggest:

1. Locking
2. Popping
3. Giving out
4. Rapid onset of large knee effusion
5. Slower onset of moderate knee effusion
6. Recurrent Knee Effusion

Answer 1

1. meniscal tear
2. ligamentous tear/rupture
3. ligamentous rupture/patellar subluxation
4. ACL rupture/tibial plateau fracture
5. meniscal tear or ligamentous sprain
6. meniscal tear

Question 2

Ottawa Knee Rule (4)

Answer 2

• obtain knee x-rays after acute knee injury ONLY in patients with at least one of the OKR rules

1. age 55 or older
2. inability to bear weight for 4 steps immediately after injury or in emergency setting
3. inability to flex knee to 90 degrees
4. tenderness over head of fibula or isolated to patella w/o other bony tenderness

Question 3

Anterior Cruciate Ligament (ACL) injury

Answer 3

• most commonly injured knee ligament
• contact injury (30%) –> fixed leg with direct blow
• non-contact (70%) –> sudden deceleration/change in direction
• large effusion (2 hrs), popping sensation, knee instability
• lead to osteoarthritis 10-20 years after initial injury

Question 4

Meniscal Injuries

Answer 4

• common knee injury from either medial/lateral meniscus

- slow pain with effusion (24 hrs), locking/catching during extension

Question 5

Patellofemoral Pain Syndrome

Answer 5

• most common cause of anterior knee pain in adolescents and adults < 60 yo
• “pain under patella”, worsens with ascending/descending stairs or prolonged sitting

Question 6

Tibial Apophysitis (Osgood-Schlatter Disease)

Answer 6

• children 9-14 yo in sports
• children with recent rapid growth spurt, gradually worsening anterior knee pain
• tenderness of bony prominence over tibial tuberosity

Question 7

Pes Anserinus Pain Syndrome (PAPS)

Answer 7

• common cause of medial knee pain

- sudden onset knee pain inferior to medial joint line worsened by repetitive knee flexion/extension

Question 8

Illiotibial Band Syndrome (ITBS)

Answer 8

• second most common cause of knee pain after patellofemoral pain syndrome
• seen in cyclists and runners
• slow onset, diffuse, lateral knee pain/leg pain
• Noble Test = lateral decubitus position with knee passively flexed to 60 degrees, (+) –> if TTP over lateral lateral femoral epicondyle during maneuver

Question 9

Plantar Fasciitis

Answer 9

• common cause of adult foot pain
• microtears in plantar fascia (acute inflamm/degen)
• sharp, stabbing, medial, plantar hip pain
• pain worse with passive dorsiflexion

Question 10

Roll Stretch with cold water bottle/can

Answer 10

• treatment of plantar fascitis

Question 11

Ankle Sprain

Answer 11

• lateral sprains most common (sports injury)

Question 12

Ottawa Ankle Rule (2 requirements for imaging)

Answer 12

1. tenderness to palpation over Medial/Lateral Malleolus

2. Tenderness over base of 5th metatarsal or navicular

Question 13

Gout Flare

Answer 13

• precipitation of MSU crystals in joint space leading to inflammatory rxn
• most commonly involves 1st metatarsophalangeal joint
• negative birefringement needle-shaped crystals on polarized light

Question 14

Anterior Drawer Test

Answer 14

positive = excessive translation

indicates: ACL insufficiency

Question 15

Lachman’s Test

Answer 15

positive = inc. laxity, soft/absent end point

indicates: ACL insufficiency

MORE SENSITIVE THAN ANTERIOR DRAWER

Question 16

Posterior Drawer Test

Answer 16

positive = excessive translation

indicates: PCL insufficiency, posterior capsule injury/disruption

Question 17

McMurrays Test

Answer 17

Lateral Meniscus –> internal rotate/varus stress
Medial Meniscus –> external rotate/valgus stress

flexed postion into full extension

positive = pain or palpable click during extension

indicates: possible medial/lateral meniscus tear

Question 18

Apley’s Grind Test - Compression

Answer 18

positive = pain w/rotation and/or compression

indicates = possible meniscus/collateral ligament injury, or both

Question 19

Apley’s Grind Test - Distraction (2 outcomes)

Answer 19

(+) pain with distraction = collateral ligament damage

(+) relief of pain = meniscus injury

Question 20

Patella-Femoral Grinding Test

Answer 20

• push on patella and patient tightens quadriceps

positive = crepitus/pain

indicates = roughness of articulating surfaces