Lower Extremity Disorders: THE KNEE: WORK-UP AND TREATMENTS COPY Flashcards
DDx of Knee pain in the following pts:
- Teen pt under 20? 4
- Adult pt 20-48 YO? 5
- Older pt >48? 3
- Teen patient (under 20 yrs)
- Patellofemoral syndrome (PFS) 95%
- Tendinitis (patellar)
- Osgood-Schlatters
- Osteochondritis Dissecans (OCD) - Adult patient (20-48 yrs)
- PFS
- Meniscus tear
- Ligament tear
- Bursitis (prepatellar)
- Tendinitis (IT band friction) - Older patient (>48 yrs)
- Meniscus tear
- Arthritis
- Bursitis (pes)
Injury Associated Events we should ask about on Hx for knee injury?
4
- Pop heard or felt
- Swelling after injury (immediate vs delayed)
- Catching/Locking
- Buckling/Instability
HISTORICAL CLUES TO
KNEE INJURY DIAGNOSES
- Noncontact injury with “pop”? 1
- Contact injury with “pop”? 3
- Acute swelling? 5
- Lateral blow to the knee? 1
- Medial blow to the knee? 1
- Knee “gave out” or “buckled”? 2
- Fall onto a flexed knee? 1
- ACL tear
2.
- MCL or LCL tear,
- meniscus tear,
- fracture
3.
- ACL tear,
- PCL tear,
- fracture,
- knee dislocation,
- patellar dislocation
4. MCL tear
5. LCL tear
6.
- ACL tear,
- patellar dislocation
7. PCL tear
12 year old female presents with nonspecific anterior knee pain. Worse with activities like running, squatting, and jumping. May have some swelling. Losing confidence. No injury. Occasional popping.
- What special tests do you want to do? 3
- Medial and Lateral Patellar Glide
- Patellofemoral Grind
- Patellar apprehension test
- What is the Patellofemoral Grind?
- Whats a positive sign for it?
- Whats the Patellar apprehension test?
- Whats a positive sign?
- Pressure on superior patella as patient fires quads
- Pain is positive exam
- Apply medial forces to patella- forcing it laterally
- Apprehension is positive exam indicating previous subluxation or dislocation
12 year old female presents with nonspecific anterior knee pain. Worse with activities like running, squatting, and jumping. May have some swelling. Losing confidence. No injury. Occasional popping.
- Dx?
- How common is this?
- How to make the Dx? 4
- Tx? 3
- PFS/ Chondromalacia
- VERY COMMON!
- Dx-
- look for muscle imbalance,
- flexibility issues,
- feet
- alignment
4.
- Tx- NICER
- Patellar stabilizing brace
- PHYSICAL THERAPY to correct deficits
18 year old female basketball player on breakaway layup goes down under the basket with no one around – ends up on the floor holding her knee and screaming in pain.
Felt a “pop”. Unable to continue. Experienced instability and increased stiffness.
Dx?
ACL TEAR
18 year old female basketball player on breakaway layup goes down under the basket with no one around – ends up on the floor holding her knee and screaming in pain.
Felt a “pop”. Unable to continue. Experienced instability and increased stiffness.
Special Tests
Assess stability of 4 knee ligaments via applied stresses
The stabilizing roles of each ligament include:
- The medial collateral ligament (MCL) prevents the knee from what?
- The lateral collateral ligament (LCL) prevents the knee from what?3. The anterior cruciate ligament (ACL) prevents what?
- The posterior cruciate ligament (PCL) prevents what?
- buckling inwards (valgus injury)
- buckling outwards (varus injury)
- the tibia from sliding forward under the femur
- the tibial from sliding backward under the femur
KNEE LIGAMENTS
Valgus and Varus at ________ flexion then ______ extension
- 30 degrees
- full
Knee ligaments: What is the Bohler test?
Valgus stress for MCL
Varus stress for LCL
COLLATERAL LIGAMENT INJURIES
Tx? 3
Timeline? 2
- Tx- NICER
- Brace
- Pain free activity
Time
- 2-8 weeks based on grade
- 1 year for full maturation of scar in complete tear
Special tests for the ACL?
3
- Lachman
- Anterior Drawer
- Pivot Shift
Don’t do- causes pain and isn’t necessary. Difficult exam. Insensitive and inaccurate while awake.
Describe how to accomplish the following tests:
- Lachman? 2
- Anterior Drawer? 2
- Lachman
- Supine, knee at 20-30 degrees flexion, & RELAXED
- >5mm anterior translation of tibia positive - Anterior Drawer
- Supine, hip at 45 degrees, knee at 90 degrees
- Tibia directed toward examiner
ACL tear
- Contact or non?
- Gender?
- Cause?
- Dx? 4
- Tx depends on? 3
- Most noncontact
- Females higher prevalence
- Muscle imbalance and mechanics- valgus load
4.
- Hx,
- exam,
- aspiration
- MRI
5. Surgical vs Non-op - Age,
- activity,
- concomitant injury
SPECIAL TEST- LIGAMENT
PCL? 2
- Sag Sign
- Posterior drawer
Describe the following and what makes them positive:
- Sag sign?
- Posterior Drawer?
Sag Sign
1.
- Same position as anterior drawer
- Thumb slides medial to patella into tibial condyle
2. Positive sign is lacking condyle
Posterior Drawer
1.
- Position as for anterior drawer
- Posterior pressure on tibia
2. Positive is posterior translation of tibia
PCL TEAR
- Cause?
- Dx? 3
- Tx? 3
- Hyperextension or posterior load (dashboard)
2.
- Hx,
- exam,
- +/- aspiration
3.
- Tx- PT- quad strengthening
- Bracing
- Occasionally surgery