MSK - the knee

Question 1

Name 2 common arthrogenic hypothesis for a knee injury and name their mechanisms, who they affect most commonly and what pain/ symptoms they produce

Answer 1

1. Osteoarthritis
Insidious mechanism (gradually progresses)
Likelihood increase with age, common over 55
Deep ache, often occurring with activity
2. Intra-articular
Trauma mechanism
Common under the age of 40
Locking/giving way of joints

Question 2

Name 2 common myogenic hypothesis for a knee injury and name their mechanisms, who they affect most commonly and what pain/ symptoms they produce

Answer 2

1. Tendonitis
Caused by overload, or change in activity
Normally occurs in those under 55
Pain increases at start and post-activity
2. Soft tissue/muscular injury
Trauma or sudden onset
Affects any age
Pain is local to tissue in question

Question 3

Name 2 common hypothesis which are a combination of myogenic and arthrogenic for a knee injury and name their mechanisms, who they affect most commonly and what pain/ symptoms they produce

Answer 3

1. AKP (anterior knee pain)
2. PFPS (patellofemoral pain syndrome)
   Anterior pain
   Insidious mechanism
   Ache, position and activity dependant

Question 4

Name a red flag hypothesis for a knee injury and name the mechanisms, who they affect most commonly and what pain/ symptoms they produce

Answer 4

1. Bone tumour
   Likelihood increases with age
   Constant pain - pain at night and rest

Question 5

Name 2 arthrogenic red flag hypotheses for a knee injury and name their mechanisms, who they affect most commonly and what pain/ symptoms they produce

Answer 5

1. Inflammatory or infectious (e.g gout)
Insidious mechanism
Common in 40-60 year olds
Constant but variable pain. Am stiffness>30 mins
2. Fracture
Trauma onset
Common in adolescent and older (osteoporosis)
Aggravated by activity, eases with rest

Question 6

Name a myogenic red flag hypothesis for a knee injury and name the mechanism, who it affects most commonly and what pain/ symptoms it produces

Answer 6

1. Rupture of tendon
   Caused by over-load
   Most common in men aged 30-40
   immediate pain then a loss of function

Question 7

What are the Ottawa knee rules?

Answer 7

Set of criteria that guide a clinician as to when an X-ray of the knee is required.
It provides a fast and accurate decision-making tool.

Question 8

What is the set of criteria laid out by Ottawa knee rules?

Answer 8

X-ray should be performed if any of the criteria are met:

• Aged 55 years or greater
• Isolated patellar tenderness
• Tenderness of the fibular head
• Inability to flex knee to 90degrees
• Inability to weight bear immediately after injury and in the emergency department

Question 9

What special questions should be asked for the knee in a subjective examination?

Answer 9

• any locking or giving way (with or without pain)
• any persistent loss of ROM
• any unexplained swelling or warmth
• any pain in hip or groin

Question 10

What should be asked for past medical history in a subjective examination?

Answer 10

THREADS:
Thyroid
Rheumatoid (or other) Arthritis
Epilepsy
Asthma
Diabetes
Surgery

Question 11

What red flags could be brought up?

Answer 11

• previous history of cancer
• unexplained weight loss (first noticeable symptom of cancers of the esophagus, pancreas and stomach as a tumor can press on the stomach and can make you feel full faster)
• night pains and sweats
• recently unwell (fever/infection)

Question 12

What would you palpate during the objective assessment?

Answer 12

• joint lines of the knee
• patellofemoral
• soft tissue tendon insertions
• mid muscle
• posteriorly

Question 13

Name some functional tests that could be carried out for the knee objective assessment.
What should be considered when performing these?

Answer 13

Squat
Sit to stand
Single leg balance
Step up
Gait analysis
Consider:
 - power
 - ROM
 - pain response
 - proprioception
 - balance

Question 14

Describe the tests for ACL involvement

Answer 14

1. Lachmans test
   - bring knee to 45degrees
   - one hand holds femur on the outside, other hand holds the tibia on the inside
   - move knee back and forth
2. Draw test
   - bring knee to 90degrees and hip to 45degrees
   - sit on foot to maintain position
   - hands around knee, with fingers in the back and thumbs on the patella
   - thumbs palpate joint lines
   - move tibia anteriorely

Positive result = soft end feel

Question 15

Describe the test for PCL involvement and what a positive result looks like

Answer 15

Posterior sag test
Lay patient in the supine position, flex knees to 90degrees and hips to 45degrees
Compare position of tibia to femur
OR
Raise leg so hips and knee and flexed to 90degrees
Support the leg under the calf
Compare position of tibia to femur

Positive result = Posterior drop of the tibia
Negative result = Tibia remains straight

Question 16

Name and describe the test for an MCL tear and what a positive result would look like.

Answer 16

Valgus stress test

• begin in a supine position
• hold the lower leg, just above the ankle (medial side)
• other hand stabilises the lateral side of the femur
• externally rotate tibia
• slight passive abduction
• causes stress on MCL
• looking for pain produced and excessive gapping on the medial side

Question 17

Name and describe the test for a LCL tear and what a positive result would look like.

Answer 17

Varus stress test

• begin in a supine position
• hold the lower leg, just above the ankle (lateral side)
• other hand stabilises the medial side of the femur
• laterally rotate the tibia
• slight passive adduction of the ankle
• looking for pain produced and excessive gapping on the lateral side

Question 18

Name and describe 3 tests for meniscal damage and what a positive result would look like.

Answer 18

1. Thessaly test
   - always compare with good leg
   - single-leg stand on injured leg, flex to 20degrees
   - hold plinth for support if necessary
   - rotate 3 times
   - positive result = pain in the joint line
2. Duck walk
   - only for those with a small meniscal tear and reasonable ROM as it is an extreme position
   - squat all the way down, onto toes
   - walk forward and backward
   - positive result = pain
3. McMurrays test
   - begin in supine position
   - fully flex knee
   - rotate tibia medially and extend knee (lateral meniscus)
   - rotate tibia laterally and extend knee (medial meniscus)
   - repeat 3 times
   - positive result = clicking, locking or pain

Question 19

Name and describe the test for patellofemoral pain and what a positive result would look like.

Answer 19

Patellofemoral sweep/compression

• place webspace on superior border of patella
• patient contracts quads
• apply a downward and inferior pressure onto the patella
• positive result = pain on movement or inability to complete the test

Question 20

Name and describe the test for patella dislocation and what a positive result would look like.

Answer 20

Patella apprehension test

• begin in a supine position
• both thumbs press on medial side of patella
• repeat by pushing on the lateral side
• positive result = uncomfortable when it reaches point of maximal lateral/medial displacement

Question 21

Describe how ligament injuries can be classified

Answer 21

Grade I
 - low force trauma
 - ligament stretch
 - pain 
 - minimal instability
Grade II
 - higher force trauma
 - more pain
 - increasing instability
 - partial tear
Grade III
 - high force trauma
 - pain and functional loss
 - marked instability
 - severe or complete tear

Question 22

How would you measure ROM at the knee

Answer 22

Goniometer
Axis on the lateral epicondyle of the femur
Moving arm on the lateral midline of the fibula, pointing at the lateral malleolus
The stationary arm on the lateral midline of the femur, pointing at the greater trochanter
ALWAYS COMPARE WITH THE GOOD SIDE

Question 23

Suggest an exercise for improving strength at the knee joint

Answer 23

Quad sets = Sit on plinth with the injured leg out straight, and pillow below the knee. Press the back of your knee into the pillow by tightening the muscles of your thigh. Dorsiflex your ankle to help.
Hamstring curls = hold onto plinth, bring injured leg up towards bottom and hold for 5 seconds

Question 24

Suggest an exercise for improving ROM at the knee joint

Answer 24

Seated scoots = Sit all the way back in a chair with your feet flat on the floor. Scoot forward, while keeping your feet firmly on the floor. You should feel a stretch along the front of your knee. Hold for 20 seconds.

Question 25

What are the muscles of the hamstring group called?

What action do they perform?

Answer 25

Biceps femoris, Semitendinosus, Semimembranosus

Prime movers of leg flexion at the knee.

Question 26

Name the origin and insertion of the biceps femoris

Answer 26

Arises from 2 heads (long head and short head)
Origin;
Ischial tuberosity (long head)
Linea Aspera (short head)
Insertion;
Head of the fibula and lateral condyle of tibia

Question 27

Name the origin and insertion of the semitendinosus

Answer 27

Origin; Ischial tuberosity

Insertion; Medial condyle of the tibia

Question 28

Name the origin and insertion of the semimembranosus

Answer 28

Origin; Ischial tuberosity

Insertion; Medial condyle of the tibia

Question 29

What nerve supplies the hamstring muscles?

Answer 29

The group is innervated by the sciatic nerve

Question 30

How do you palpate the medial collateral ligament?

Answer 30

Begin with the leg in flexion
Find the joint line, above the tibial tuberosity
Run your finger along the joint line posteriorly until your finger is “pushed out”.

Question 31

Name the muscles on the anterior of the thigh

Answer 31

Quadricep group;
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius

Question 32

Name the origin and insertion for all muscles in the quadricep group

Answer 32

All 4 muscles originate from;
anterior inferior iliac spine and linea aspera
All 4 muscles insert into;
patella and tibial tuberosity via the patellar ligament