Physical Examination of Overuse/ Chronic Knee Conditions Flashcards
What is the order of the P/E for knee conditions?
- observation
- Fx tests
- palpation
- active movements
- passive physiological movements
- passive accessory movements
- special tests
- other jt assessment
- neurodynamic tests
What do you observe with knee conditions? (3)
- standing
- gait
- supine
What functional tests can you do for the knee?
- squat (DL & SL)
- lunge
- jump/hop
- stairs
- running
- drop down
What to palpate with the knee?
- Patella: med and lat facets
- Med and Lat retinaculum
- patella tendon (prox, mid, belly, distal)
- quadriceps tendon
- Hoffas fat pads
- lat femoral condyle
- superior tib-fib jt
- biceps tendon
- med and lat TF lines
What active movements are done with knee conditions?
- knee flexion
- knee extension
- repeated knee flexion
- muscle length testing of quads, hammys, gastrocnemius and soleus
What passive physiological movements are used for knee conditions?
- knee flexion
- knee extension
- tibial IR/ ER
- hip all ranges
- Lsp all ranges
Passive accessory movements for knee conditions?
- PF jt: med and lat glides
- PF jt: ceph and caud glides
- TF jt: AP/ PA glides
- TF jt: med/lat glides
- sup tib-fib jt: AP/PA glides
What special tests for the knee
- knee examination as per acute knee lecture
- over pressure +/- knee flex/ect
- McConnell resisted ext test
Other jt assessments (clearing)
- examination of lumbar spine
- examination of hip jt
- examination of ankle jt
Neurodynamic tests for knee conditions
- SLR
- slump test
- prone knee bend
- neural thomas test
ANTERIOR KNEE PAIN
What are the most common anterior knee pain conditions? (2)
- Patellofemoral Pain Syndrome (PFPS)
- Patellar tendinopathy
What are the less common anterior knee pain conditions (3)?
- Hoffas Fat Pad impingement
- Sinding - Larsen - Johansen lesion in adolescents
- Osgood- Schlatter lesion in adolescents
What are the conditions NOT TO BE MISSED in anterior knee pain (3)?
- osteochondritis dessicans
- slipped capital femoral epiphysis
- perthes’ disease
Definition of PFPS:
all peripatellar / retropatellar pain in the absence of other pathologies (no mensical/ ACL etc.)
What are some synonyms for PFPS?
- PFJP (patellofemoral joint pain)
- PFPS
- anterior/ retropatellar pain
- chondromalacia patellae (death of patella cartilage)
Chondromalacia Patellae
refers to the state of the patellar articular cartilage –> poor correlation between articular cartilage damage and PFP
What can a cartilage lesion lead to?
chemical/ mechanical synovial irritation, oedema / erosion which contain nociceptors –> = pain
What else could PFP be due to?
patella maltracking
What is patella maltracking due to?
VL & VMO imbalance
ITB tightness
What type of factors contribute to PFPS?
extrinsic & intrinsic risk factors
What is the definition of extrinsic risk factors?
increased/ unaccustomed PFJ load
extrinsic risk factors e.g.s
body mass, surfaces, footwear, volume of work, increase in amount of knee flexion required for task, eccentric work
What do intrinsic risk factors refer to?
patella alignment in femoral trochlea (patella tracking)
Local factors relating to patella tracking (intrinsic risk factors) (2)
- patella position
- quadriceps (strength/ imbalance)
Remote factors relating to patella tracking (intrinsic factors) (6)
- increased femoral internal rotation
- increased hip adduction
- increased knee valgus/ external tibial rotation
- poor trunk & pelvic control
- pronated foot type
- increased knee flexion
How can the patella be maltracked? – different patella positions (5)
- lateral displacement – closer to lateral femoral trochlea groove
- lateral tilt - high medial border
- posterior tilt - inferior pole moves posteriorly
- patella alta - high riding patella
- patella baja - low riding patella
What happens to the quadriceps muscles that contributes to patella maltracking & PFP? (5)
- reduced peak knee extension torque
- quadriceps atrophy
- reduced quads flexibility
- delayed VMO onset compared to VL - they should come on together
- reduced hammy flexibility
How does the Q angle effect PFP?
increased/ decreased Q angle causes pressure through patella
PATIENT HISTORY - PFP
What is the type of pain on the body chart?
often vague- ill defined –> poorly localised
Is PFP bilateral?
can be
what may the patient report with PFP?
giving way, crepitus, swelling, locking, clicking
Aggs of PFP
Loaded knee flexion activites
- running, stairs, kneeling, squatting, lunging
Prolonged sitting with knee flexed
- can be referred o as “moviegoers” knee
How much BW is loaded into the patella with walking
0.3 x
How much BW is loaded into the patella with climbing stairs
2.5 x
How much BW is loaded into the patella with descending stairs
3.5 x
How much BW is loaded into the patella with squat
7 x
PHYSICAL EXAMINATION OF PFP
what do you observe in PFP? (4)
- swelling present locally / intracapsular
- quads wasting (inhibition)
- patella alta / baja
- patella tilting
What do you palpate in P/E of PFP?
- tenderness medial / lateral aspects of patella
- medial / lateral retinaculum
Expected ROM for PFP?
often full ROM, but can be painful with flexion & muscle contraction in extension
What functional assessments can be used for PFP?
squat, lunge, step down, running, jumping
PATELLA TENDINOPATHY (PT)
What is it?
overuse condition causing degeneration & local pathology of patella tendon
What is Patella tendinopathy first referred to as?
jumpers knee
What are the risk factors for Patella Tendinopathy? (7)
- higher body mass index (BMI)
- higher waist - hip ratio
- leg length difference >3cm
- lower arch height of foot
- reduced quads & hammy flexibility
- strength
- change in load
What are other risk factors for Patella Tendinopathy (5)?
- age – young males
- playing at national level
- males
- volleyball
- position playe
PT MOI
- repetitive mechanical loading of the tendon
- linked to sudden spike in load
is PT gradual / trauma caused?
insidious / gradual onset
How do patients usually report subjectively? (6)
- progressively worsening
- decreased functional ability (ADLs)
- pain over patella tendon near inferior pole of patella
- commonly morning stiffness
- pain worsens after activity
- “warms up” with movement
PT aggs (6)
- jumping/ power based mvmt
- running
- change in direction
- deceleration
- stairs
- prolonged sitting
PT easing factors?
- movement
- unloading e.g. tape / bracing
PT observations (2)?
- may have localised swelling / thickening inferior to patella
- consider local & remote intrinsic factors
PT palpation (3)?
- tenderness of palpation of patella tendon, inferior pole of patella, tibial tuberosity
- associated with thickening of tendon
- crepitus if paratendonitis present
PT ROM?
often full range
- may experience pulling at EOR flexion
PT Fx tests?
decline squat (30 deg) –> eccentric load
- may reproduce pain on lunge, hop, jump and / or eccentric loading
PT other tests?
- MMT
glutes, hammy, quads, calf - Jt ROM
Lsp, Hip, Knee, Ankle
Questionnaire –> VISA -P
What happens during the healing of PT that you can see on an ultrasound?
neovascularisation –> new blood vessels form
How to DD between PFP and PT?
Body chart
PT = localised pain to inferior pole of patella etc. vs vague ache of PFP
How to DD between PFP and PT?
Observation
PT = thickening around patella tendon in infrapatella region
- no jt effusion
How to DD between PFP and PT?
Palpation
PT = localised tenderness to inferior pole of patella, mid belly / tibial tuberosity
How to DD between PFP and PT?
ROM
PT = tightness/ pulling in EOR knee ext
How to DD between PFP and PT?
Fx Tests
PT = decline squat - eccentric loads reproduce pain
