Week 5- Knee Clinical Presentations Flashcards
PART 1: COMMON PRESENTATIONS AND FRACTURE SCREENING
PART 1: COMMON PRESENTATIONS AND FRACTURE SCREENING
Knee Pain Common Clinical Presentations.
- Patellar Fracture
- Tendon Rupture
- Osgood-Schlatter Disease
- Articular Cartilage Defects
- Meniscus Lesion
- Cruciate & Collateral Ligament Sprains
- Patellofemoral Instability
- Patellofemoral Pain Syndrome
- Osteoarthropathy
- Arthrofibrosis
- Genu Recurvatum
- Patellar Tendinopathy
- ITB Friction Syndrome
- Plica Syndrome
- Bursitis
- Osgood-Schlatter Disease
- Peripheral Nerve Entrapment
What are the 2 Decision Rules for Fracture Screening at the knee?
- Pittsburgh Knee Decision Rule
- Ottawa Knee Decision Rule
What are the (3) criterion for the Pittsburgh Knee Decision Rule?
- ) Hx trauma/fall
- ) Instability to bear weight x 4 steps immediately and in ED
- ) Age <12 OR >50
What are the (5) criterion for the Ottawa Knee Decision Rule?
- ) TTP head of fibula
- ) Instability to bear weight x 4 steps immediately and in ED
- ) Age >/= 55 years
- ) Inability to flex knee 90 degrees
- ) Isolated TTP patella
What are the Pittsburgh and Ottawa Knee Rules used for?
-Used to identify which cases of knee injury require radiographic imaging.
PART 2: PATELLAR FRACTURE
PART 2: PATELLAR FRACTURE
Patellar Epidemiology:
- Makes up ___% of all fractures.
- Most common ___-___ y/o.
- ______ 2x > _______
- 50% ___-________
- 1%
- 20-50
- males 2x > females
- non-displaced
What are (2) common MOIs for patellar fracture?
- Fall onto anterior knee.
- Sudden quad activation.
Patellar Fracture Symptomology:
-In a patellar fracture the patient will report ________ knee pain and painful/inability to _______ the knee.
- anterior knee pain
- inability to extend knee
Patellar Fracture Physical Examination:
- Palpable gap at fracture site.
- Local tenderness.
- Painful ___________ > _______ for knee extension.
- Painful end-range _______ ROM.
- Antalgic gait.
- painful resistance testing > AROM
- painful end range flexion
PART 3: TENDON RUPTURE (PATELLAR AND QUAD)
PART 3: TENDON RUPTURE (PATELLAR AND QUAD)
Tendon Rupture Epidemiology:
- _______ Tendon Rupture = < 40 y/o.
- _______ Tendon Rupture = > 40 y/o.
- Which tendon rupture is 4-8x more likely in males?
- Patellar tendon rupture = <40 y/o
- Quad tendon rupture = >40 y/o
- Quad tendon rupture
What are the risk factors for tendon rupture? (7)
- local steroid injection
- prolonged corticosteroid use
- RA/Lupus
- CT (connective tissue)/infectious diseases
- Arteriosclerosis
- DM
- Hyperthyroidism
Tendon Rupture History:
- Related to _______ overload extensor mechanism/trauma.
- Sudden onset f/b fall.
- Quad rupture common MOI?
- Patellar rupture common MOI?
- Hx of what 3 things?
- eccentric overload
- rapid quad contraction (regaining balance)
- jump landing
- Hx of degenerative tendinopathy, TKA, and ACL reconstruction.
Tendon Rupture Symptomology:
-Where will patients with quad/patellar ruptures report pain?
-anterior knee
Tendon Rupture Physical Examination:
- Absent/painful active knee __________.
- Painful knee _______ ROM.
- Palpable defect.
- Antalgic gait/unable to walk.
- Absent/painful active knee extension.
- Painful knee flexion ROM.
PART 4: OSGOOD SCHLATTER DISEASE
PART 4: OSGOOD SCHLATTER DISEASE
What is Osgood Schlatter Disease?
-Apophysitis (inflammation to growth plates) of tibial tubercle.
Osgood Schlatter Epidemiology/Hx:
- What population is this most common in?
- Involves repetitive loading into knee ________.
- Common __________.
- young adolescent (males (10-15) > females (8-13))
- flexion
- bilaterally
Osgood Schlatter Disease Symptomology:
-Patient will report pain in ________ knee and aggravation with _______/resisted knee ________.
- pain in anterior knee
- aggravated with activity/resisted knee extension
Osgood Schlatter Disease Physical Examination:
- Local TTP
- Prominent ______ ______ on visual inspection.
- Pain end-range knee ______ ROM.
- Knee __________ pain with resistive testing > AROM.
- Possibly painful with tuning fork.
- prominent tibial tubercle
- pain end-range knee flexion
- knee extension pain resistive > AROM
PART 5: ARTICULAR CARTILAGE DEFECTS
PART 5: ARTICULAR CARTILAGE DEFECTS
What is Osteochondritis Dissecans?
-Type of articular cartilage defect involving the separation of articular cartilage from subchondral space.
Osteochondritis Dissecans Epidemiology:
- What is the most common site?
- Is it more common in males or females?
- Greatest ___-___ y/o active individuals.
- Common _________.
- Most common on lateral side of medial condyle.
- males > females
- 10-20 y/o active individuals
- bilaterally
Osteochondritis Dissecans Hx:
- Traumatic MOI (40-60%) juveniles vs. insidious.
- ___________ within 2 hours. What is this?
-Hemiarthrosis within 2 hours. Hemiarthrosis is articular bleeding into the joint cavity.
Osteochondritis Dissecans Symptomology:
- ___________ knee pain.
- Does activity make it better?
- Stiffness/swelling with activities.
- ________/________/_______
- non-specific knee pain
- No, activity makes it worse and rest makes it better.
- grinding/locking/catching
Osteochondritis Dissecans Physical Examination:
- TTP at the femoral _______, medial and lateral joint lines.
- Antalgic gait
- Knee effusion.
- Limited painful knee _________.
- TTP at femoral condyle
- limited/painful knee ROM (flexion/extension)
What are some common surgical interventions used for articular cartilage defects? Explain each.
Arthroscopic lavage & debridement
-Probe with debridement of loose fragments.
Microfracture
-If chondral, drill holes leading to bone supply for vascularization.
Autologous Osteochondral Mosaicplasty Grafting
-Cartilage taken from other areas and placed.
Autologous Chondrocyte Implantation (ACI)
-Grow in lab, place back in.
PART 6: MENISCUS LESION
PART 6: MENISCUS LESION
Meniscus Lesion Epidemiology/Hx:
- Incidence 12-14%
- What injury is often concomitant with a meniscus lesion?
- Audible “pop” during _____________.
- Delayed _________ (__-__ hours following injury)
- ACL Injury
- directional change
- delayed effusion (6-24hrs)
Meniscus Lesion Symptomology:
- _______/_______/__________ at the knee.
- Local knee pain.
-catching/locking/giving way of knee
Meniscus Lesion Physical Examination:
- Pain at end-range knee _________.
- Pain/limited _______ ROM.
- Painful/weak ___________ resistive testing.
- What 4 tests may be + if Meniscus Lesion is present?
- end-range knee extension
- pain/limited flexion ROM
- flex/ext resistive testing
- McMurray’s, Thessaly, Appley’s. Varus/Valgus Stress Tests
PART 7: ACL, PCL, MCL, LCL
PART 7: ACL, PCL, MCL, LCL
- What is the function of the ACL?
- What is the function of the PCL?
- What is the function of the MCL?
- What is the function of the LCL?
- ACL = Prevent anterior translation of tibia on femur.
- PCL = Prevent posterior translation of tibia on femur.
- MCL = Prevent valgus collapse.
- LCL = Prevent varus collapse.
ACL Epidemiology:
- What is a common issue that occurs years after ACL injury?
- ACL injury increases the risk to what else?
- Knee OA
- Stabilizers of the knee.
ACL Clinical Correlations:
- _______ 2-9x more likely. Why?
- Decreased ________/_____ strength.
- Duration of activity/fatigue.
- Dry/artificial turf.
- High BMI.
- Females 2-9x due to jump landing mechanisms, greater Q angle, narrower intercondylar notch, and hormone laxity.
- Decreased hamstring/core strength.
ACL Hx:
- Are ACLs more likely from contact or non-contact?
- What are some MOIs?
- Contact injury MOI involves varus/valgus stress imposing shear force on joint.
- More likely from non-contact.
- Pivoting with planted foot and extended knee, cutting maneuvers, landing in full knee extension, hyperextension/hyperflexion.
ACL Symptomology:
- Feelings of ________ at knee.
- C/o severe pain with audible _____ and immediate _______.
- Feelings of instability.
- C/o severe pain with audible “pop” and immediate swelling.
ACL Physical Examination:
- ________-________ posture
- Knee joint effusion
- Antalgic gait
- AROM/PROM/Resistive painful/limited in what plane?
- _____/________ end-feel.
- Excessive laxity with KT-1000 arthrometer test.
- What 3 tests may be + with ACL Sprain?
- weight-shifted posture
- AROM/PROM/Resistive limited/painful in ALL PLANES.
- Boggy/guarded end-feel
- Pivot Shift, Anterior Drawer, Lachman’s Tests
PCL Epidemiology/Hx:
- __-__% of knee injuries.
- Audible _____ with injury.
- What are some common MOIs?
- 3-20% of knee injuries
- audible “pop”
- Posterior force at proximal anterior tibia, violent hyperextension, fall on flexed knee with PF.
PCL Symptomology:
- Local _________ knee pain aggravated with deceleration and kneeling.
- Feeling of LE _________.
- local posterior knee pain
- Feeling of LE giving way (instability)
PCL Physical Examination:
- Limited knee _______ in stance phase of gait.
- Effusion
- Limited/painful knee _______ ROM.
- Painful with resistive testing of extension > 90 degrees.
- What test may be + with PCL Sprain?
- limited knee extension in stance phase
- Limited/painful knee ext/flex
- Posterior Drawer Test
MCL Epidemiology:
- Is this injury concomitant with other ligamentous injuries at the knee?
- Correlation with soccer/football/hockey.
- High grade injuries may lead to chronic knee ___________.
- What do we need to worry about with deep MCL tears?
Yes, involved in ~42% of ligament injuries at the knee.
- chronic knee instability
- Worry about connection with meniscus.
MCL Hx:
- Is this more common in younger/older, and male/female?
- What is a common MOI?
- Younger, males (2x)
- Valgus force (external force at lateral knee)
MCL Symptomology:
- ______ knee pain.
- Aggravated with ________, change in _______, and ______ force.
- medial knee pain
- Aggravated with activity, change in direction, and valgus force.
MCL Physical Examination:
- Swelling/bruising
- Antalgic gait
- Potential limited/painful knee ROM
- Local TTP
- What test may be + with MCL Sprain?
- Valgus Stress Test (pain/laxity)
LCL Hx:
-What is a common MOI?
-Varus trauma at knee.
LCL Symptomology:
- _______ knee pain.
- Aggravated with change in _______ during ambulation.
- lateral knee pain
- Aggravated with change in direction
LCL Physical Examination:
- Local lateral knee effusion
- Local TTP
- Guarded/boddy end-feel with end range ROM flexion and extension.
- What test may be + with LCL Sprain?
- Varus Stress Test at 0 and 30 degrees
PART 8: PATELLOFEMORAL INSTABILITY
PART 8: PATELLOFEMORAL INSTABILITY
What is Patellofemoral Instability?
-Concern with tracking of patella and distribution of loading that can have subsequent dislocations commonly.
Patellofemoral Instability is often concomitant with _________ lesion.
-Osteochondral lesion
Patellofemoral Instability Predispositions:
- _____ patella, ______ groove
- Patella ____/_____
- Quad muscle imbalance
- Generalized ligamentous laxity
- small patella, shallow groove
- alta/baja
Patellofemoral Instability Hx:
-_________/________ of patellofemoral joint.
Subluxation/dislocation
Patellofemoral Instability Symptomology:
- ________ of LE
- _____-_______ pain
- “Giving way” of LE
- peri-patellar pain
Patellofemoral Instability Physical Examination:
- Peripatellar TTP.
- ______mobility of patellofemoral joint.
- ___________ sign.
- Acchymosis/swelling/effusion in ______ stages.
- Hypermobility
- Apprehension sign
- acute stages
Recurrent Patellofemoral Instability is an indication for surgical management. What may be done?
-May cut lateral retinaculum so it can’t pull patella out and dislocate.
PART 9: PFPS (PATELLOFEMORAL PAIN SYNDROME)
PART 9: PFPS (PATELLOFEMORAL PAIN SYNDROME)
- What population is at risk for PFPS?
- Common with what activities?
- Active individuals and adolescents.
- Weight-bearing activities.
PFPS Clinical Correlations:
- Altered patellar tracking thought to contribute to aberrant loading patterns of patellofemoral joint.
- _______ weakness/muscle imbalance
- Soft tissue tightness
- Increased __-_____
- Hip weakness (ABD/ER)
- Altered ___/____ kinematics (subtalar pronation)
- Increased femoral angle of ________
- Increased femoral _________
- Quad weakness/imbalance
- Increased Q-angle
- Altered foot/ankle kinematics
- Increased femoral angle of inclination
- Increased femoral anteversion
PFPS Hx:
- Athletes
- ______ gender
- _______ onset
- female gender
- insidious onset
PFPS Symptomology:
- ______/________ knee pain
- What are some aggravating factors?
- Knee __________
- Catching at knee
- Anterior/peri-patellar
- Aggravated with (prolonged) sitting, stair ambulation, inclined walking, squatting
- Knee crepitus
`PFPS Physical Examination:
- Patella ____/_____
- Abnormal __-______
- Painful squat
- Possible peri-patellar swelling and antalgic gait
- Painful/limited knee _______ AROM
- Painful/limited knee _______ PROM
- Hip ER/ABD weakness
- What test may be + with PFPS?
- Patella alta/baja
- Abnormal Q-angle
- Painful/limited knee flex/ext AROM
- Painful/limited knee flex PROM
- Clarke’s Test
What does the CPG say about diagnosis of PFPS?
- ) Should use reproduction fo retropatellar or peri-patellar pain during squatting as a diagnostic test for PFP. Can also use performance/functional activites that load PFJ in a flexed position such as stairs. (A GRADE)
- ) Should make diagnosis of PFP using criteria (1) Presence of retropatellar or peri-patellar pain (2) Reproduction of retropatellar or peripatellar pain with squatting, stair climbing, prolonged sitting, etc in flexed position of PFJ (3) Exclusion of all other conditions. (B GRADE)
- ) May use the patellar tilt test with the presence of hypomobility to support diagnosis of PFPS.
PART 10: OTEOARTHROPATHY (OA)
PART 10: OTEOARTHROPATHY (OA)
What is OA?
-Any disease of the bones and joints.
- What joint is most commonly affected by OA?
- Patients with a previous ______ injury are more likely to develop knee OA.
- Can be ____________.
- Knee
- ACL injury
- asymptomatic
- Early OA = joint _______
- Late OA = joint ________
- Early OA = joint gapping
- Late OA = joint narrowing
OA Hx:
- ______ onset
- Hx trauma/prior knee Sx
- Family Hx
- _________
- Knee ______mobility
- Joint shape abnormality
- Extreme physical activity levels
- Age >___ y/o
- _______ gender
- insidious onset
- obesity
- knee hypermobility
- age > 50
- female > male
OA Symptomology:
- ________ pain
- Aggravated with w/b activities, squatting, stairs, prolonged sitting
- _________
- Retropatellar pain
- Crepitus
OA Physical Examination:
- Antalgic gait
- Swelling/warmth at knee
- TTP joint lines
- Painful/limited knee _________
- Painful/limited resistive testing
-Painful/limited knee flex/ext
PART 11: ARTHROFIBROSIS
PART 11: ARTHROFIBROSIS
- What is arthrofibrosis?
- Is inflammation present?
- May lead to ___________ joint changes.
- Dense proliferative intra-articular and extra-articular scar tissue formation with related limitations in knee ROM.
- Yes
- degenerative joint changes
Arthrofibrosis Symptomology:
- Stiffness(worse in _________)
- Knee swelling
- ________
- ______ knee pain
- Stiffness (worse in morning)
- Crepitus
- Diffuse knee pain
Arthrofibrosis Physical Examination:
- Limited knee __________ in stance.
- Limited/painful knee _______.
- _____mobile patellofemoral glides
- Knee effusion/swelling
- Inhibited/weak/painful knee __________
- extension
- limited/painful knee ext/flex
- hypomobile
- Inhibited/weak/painful knee extension
PART 12: GENU RECURVATUM
PART 12: GENU RECURVATUM
Genu Recurvatum involves hyperextension of the knee >___ degrees.
- > 10 degrees
Genu Recurvatum Epidemiology:
- Are females of males affected more?
- Correlated with joint laxity, Hx knee injury, and poor muscular control.
- May predispose patient to what injuries? (4)
- females
- ACL injury, compressive anterior tib-fib joint injury, tensile posterior joint supporters injury, posterior corner capsulo-ligamentous avulsion injury
Genu Recurvatum Hx:
- Forced knee ________ injury.
- Jump landing in extension.
- Force to anteriomedial proximal tibia.
- Noncontact hyperextension with planted foot.
- Concomitant ____ injury.
- extension
- PCL injury
Genu Recurvatum Symptomology:
- C/o knee ____________.
- ____________ vs ____________ knee pain
- C/o knee instability
- Anteriomedial vs posteriolateral knee pain
Genu Recurvatum Physical Examination:
- Knee hyperextension (impaired __________)
- Edema, ecchymosis
- TTP locally
- ___________ screening exam
- Antalgic gait
- Hypermobility posterior glide with posteriolateral bias.
- Knee hyperextension (impaired proprioception)
- Neurovascular screening
PART 13: PATELLAR TENDINOPATHY
PART 13: PATELLAR TENDINOPATHY
- Patellar Tendinopathy is often called “Jumper’s Knee” and involved an __________ overload.
- Average ___ months pain/functional limitations.
- ___% of affected athletes quit sport.
- What sports are more prone to this injury?
- eccentric overload
- Average 32 months
- 53%
- basketball and volleyball
Patellar Tendinopathy Symptomology:
- ________ knee pain
- Aggravated with _________/ extensor mechanism
- anterior knee pain
- aggravated with jumping
Patellar Tendinopathy Physical Examination:
- TTP at what areas?
- Painful squat
- Pain end-range _______ ROM
- Pain ______ > ________
- TTP at patellar tendon and inferior pole of patella
- Pain end-range flexion
- Pain resisted > AROM extension
PART 14: IT BAND FRICTION SYNDROME
PART 14: IT BAND FRICTION SYNDROME
- IT Band Friction Syndrome involves increased compression on soft tissue structures between lateral femoral ______ and ____.
- Involved with thickening of bursa.
lateral femoral condyle and ITB
IT Band Friction Syndrome Hx:
- ___________
- Also downhill skiers, jumpng sports, weight lifters, cycling
-Long distance runners
IT Band Friction Syndrome Symptomology:
- _______ knee pain
- Aggravated with activity, repetitive knee ______/_______, and stairs.
- lateral knee pain
- Aggravated with activity, repetitive knee flex/ext, and stairs
IT Band Friction Syndrome Physical Examination:
- Local TTP
- Hip ROM painful end-range _______
- Potentially painful hip ________ resistance testing
- What test may be positive with ITB Friction Syndrome?
- end-range ADD
- ABD resistive testing
- Ober Test
PART 15: HOFFA’S SYNDROME
PART 15: HOFFA’S SYNDROME
What is Hoffa’s Syndrome?
-Hypertrophy/iniflammation of intrapatellar fat pad that can cause impingement between femoral condyles and tibial plateaus.
Hoffa’s Syndrome Hx:
-Trauma vs repetitive _______ microtrauma
-extension
Hoffa’s Syndrome Symptomology:
- _________ (infrapatellar) knee pain
- Aggravated by activities that require (repetitive) knee _________.
- anterior knee pain
- knee extension
Hoffa’s Syndrome Physical Examination:
- Painful knee _________ ROM
- Local TTP (medial/lateral to ___________)
- painful knee extension ROM
- Local TTP (medial/lateral to patellar tendon)
PART 16: PLICA SYNDROME
PART 16: PLICA SYNDROME
What is Plica Syndrome?
- A plica is a fold in the thin tissue that lines your knee joint. There are 4 (supra/medio/infra/lateropatellar plica) of these plica, and they let you bend and move your leg with ease.
- Plica Syndrome is when one of these gets irritated from injury or overuse.
Plica Syndrome Suggested Clinical Dx: -Supportive Hx. -Failure with conservative management. -Arthroscopic observation of fibrotic plica with impingement in patellofemoral joint during knee \_\_\_\_\_\_\_. No other likely diagnostic hypothesis.
-flexion
Plica Syndrome Hx:
- ______trauma
- Can happen at any age but greatest risk with __________.
- Initial knee injury with secondary inflammation to plica.
- microtrauma
- adolescents
Plica Syndrome Symptomology:
- ________ knee pain.
- clicking/catching/locking/giving way
- Aggravated with activity, prolonged standing/sitting, squatting
-anterior knee pain
Plica Syndrome Physical Examination:
- __________ plica ________ effusion.
- Local TTP
- Painful knee ______ ROM, less pain with active _________.
- Painless _______ PROM.
- Hypertrophied plica without effusion
- Painful knee flexion ROM; less pain with active extension
- Painless extension PROM
PART 17: BAKER’S CYST
PART 17: BAKER’S CYST
What is Baker’s Cyst?
A fluid-filled cyst behind the knee, may rupture.
Baker’s Cyst Symptomology:
-________ knee pain.
posterior knee pain
Baker’s Cyst Physical Examination:
- Local swelling proximal to popliteal fossa
- Pain knee ________
- Prominence of cyst increases with resisted knee _______.
- painful knee flex/ext
- Prominence increases with resisted knee flexion
PART 18: BURSITIS
PART 18: BURSITIS
What are the (3) areas this can occur?
- Superficial & deep infrapatellar (nun’s knee) = Direct mechanical irritation
- Prepatellar = Recurrent anterior knee trauma
- Superficial Pes Anserine = Swimmers/ distance runners
Bursitis Physical Examination:
-Local ____/__________
Local TTP/swelling
PART 19: NERVE ENTRAPMENTS
PART 19: NERVE ENTRAPMENTS