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Flashcards in Ankle + knee pain Deck (74):
1

ligament stretched or torn
-don't hear or feel a "pop" but swollen

sprain

2

tendon or muscle stretched or torn
- tender, tight muscle

strain

3

lateral (fibula) ligaments of ankle joint (ant to post)

#1 anterior talofibular ligament (most susceptible to acute injury)
#2 calcaneal fibular ligament
posterior talofibular ligament
peroneus longus
brevis tendons

4

medial (tibia) ligaments of ankle joint

deltoid ligament

5

primary plantar flexor

achilles tendon: attaches at posterior portion of calcaneus

6

primary everters of ankle

inferior to lateral malleolus:
peroneus brevis (attaches to distal 5th metatarsal, can cause avulsion fracture)
peroneus longus

7

primary inverter of ankle

posterior tibialis tendon: inferior to medial malleolus

8

high ankle sprain ligaments

anterior tibiofibular ligament
posterior tibiofibular ligament
syndesmosis: sheet of interosseous membrane

9

ankle injury grades

grade I: minimal swelling + pain, ATFL stretch, no instability, able to bear weight with some pain
grade II: partial tear of ATFL, stretched CFL, > pain + swelling, mild-mod joint instability, lots pain with weight bearing, loss of ROM
grade III: complete tear of ATFL and CFL, partial tear of PTFL, > joint instability, can't bear weight, loss of function

10

most common ankle injury

forced inversion with ankle in plantar flexion (tear anterior talofibular ligament)

11

causes of tendinosis (usually chronic ankle pain, d/t overuse causing inflammation, partial tendon rupture)

achilles tendon
peroneal tendon
posterior tibialis tendon

12

cause of achilles tendon rupture

jumping sports
steroid injection complication
FQ antibiotics

13

hemarthrosis think

hemophilia

14

knee pain + limp, think

hip disorder:
legg-perthes
slipped capital femoral epiphysis

15

ankle/knee pain + poor response to treatment

malignancy

16

bony swelling + ankle/knee pain

tumor

17

fever + ankle/knee pain

osteomyelitis
septic arthritis

18

if "snap" or "pop" felt

ligament rupture

19

inability to bear weight after injury think

fracture (not sprain)

20

PE for joint

ROM
strength
palpation
stability
gait

21

ottowa ankle rules to determine need for xray with ACUTE ankle injury: sensitive for ankle and midfoot fractures
must be > 6yo

pain in malleolar or midfoot zone and one of following:
bony tenderness at posterior edge or tip of either malleoli
bony tenderness over navicular(medial)
bony tenderness at base of 5th metatarsal (lateral)
inability to bear weight both immediately and in ED (4 steps)
if negative: probably not a fracture

22

talar tilt test

lateral ankle pain
anterior talofibular + calcaneofibular ligament
grasp each side of foot at talus and apply varus stress (bow out)
+ if asymmetric ROM between ankles

23

anterior drawer test

lateral ankle pain
anterior talofibular ligament
grasp calcaneus and try to slide heel forward
+ if at least 3 mm difference between ankles

24

squeeze test

anterior/lateral ankle pain
compress tibia and fibula above midpoint of calf
+ pain: syndesmosis sprain (high ankle)

25

cotton test/rocker test

anterior/lateral ankle pain
like talar tilt test - mediolateral force applied and any ROM > 3 mm is abnormal

26

eversion + dorsiflexion trauma (rare) causes

medial ankle pain:
deltoid ligament sprain (very strong)
often associated with fracture or posterior tibialis tendon injury

27

medial ankle pain think

deltoid liagment

28

posterior ankle pain think

achilles tendon:
crepitus, tenderness, swelling, gap

29

thompson (mildcalf compression) test

assess if achilles tendon is intact
lie prone with feet over edge of table
squeeze gastrocnemius and soleus
normal: plantar flexion
positive: no foot movement (complete or near complete rupture of tendon)

30

if ankle bone pain at night, bone pain without injury, or don't respond to tx get

xray

31

imaging for achilles tendinosis or achilles tendon rupture

no gold standard: U/S or MRI (good if young athlete - help with prognosis)

32

early mobilization of ankle sprain

more likely to return to sport vs brace
improve functioning
reduce pain + swelling
return sooner
less instability

33

lace up brace for ankle sprain

less likely to cause disabling swelling vs semirigid brace

34

semirigid brace for ankle sprain

return sooner vs elastic bandage
prevent ankle sprain during high risk sport if previous grade II or III tear

35

PT for ankle sprain

prevents subsequent sprains

36

acute grade I ankle sprain tx

RICE symptomatically
early mobilization: bear weight as tolerated
NSAID or acetaminophen for pain

37

acute grade II ankle sprain tx

RICE for 2-3 days
NSAIDS
immobilization in lace up splint 2-7 days, crutches

38

acute grade III ankle sprain tx

same as grade II - but longer recovery
immobilization in air-stirrup splint or below knee cast for up to 3 mo
PT afterward
if still functionally impaired or separation of tibia and fibular: need surgery

39

syndesmosis sprain tx

body weight can increase stress, pain, instability
removable splint or casting to allow for progressive weight bearing as tolerated
passive ROM - esp dorsiflexion within week of injury

40

if avulsion fragment > 2mm

immobilize in cast or splint and refer to surgeon

41

avulsion of peroneus brevis on 5th metatarsal head

heals without treatment
immobilize until weight bearing tolerated

42

refer to surgeon if

fracture of base of 5th metatarsal (jones fracture)
proximal 2nd, 3rd, 4th (Lis Franc)
growth plate (salter-harris fracture)

43

treatment of achilles tendinosis

rest, ice, heel lifts
rehab of gastroc and soleus: stretching, ROM, then strength
NSAIDS

44

treatment of achilles tendon rupture or if very active with achilles tendinosis

surgery (prevent re-rupture)

45

all patients with ankle injuries should undergo

rehab

46

knee joint

patella
tibia
femur

47

primary stabilizers of knee

ACL (insertion), PCL, MCL, LCL
menisci
joint capsule
medial and lateral retinacula attach to patella

48

knee actions

during flexion: forward translation, internal rotation of tibia
extension: rearward translation, external rotation

49

ACL role

prevent anterior movement of tibia on femur
helps MCL stabilize knee during lateral stress when knee is flexed

50

menisci role

stabilize knee during pivoting

51

popliteus m. role

attached to lateral meniscus
prevents lateral meniscus from sliding forward and getting crushed during flexion
locks knee in full extension and unlocks

52

flexed knee hits dashboard in MVA

PCL injury

53

causes of anterior knee pain: pain climbing up/down stairs, squatting, pronged sitting, snap/pop/click/catching of knee

patellar tendonitis
patellofemoral dysfunction
chondromalacia patellae

54

sudden swelling of knee

hemarthrosis (most commonly associated with ACL tear, osteochondral fracture in 10%)

55

hear or feel pop think

ACL tear

56

knee gets "stuck" during ROM

meniscus injury or loose joint body (cartilage)

57

stiffness with inactivity - improves after few minutes (vs RA), pain with weight bearing activity

DJD

58

lachman test

ACL Tear
knee flexed at 20-30 deg
stabilize femur, other hand on proximal tibia - try to slide tibia forward
+ if: >3 mm difference or no endpoint

59

posterior drawer test

PCL tear
flex knee to 90 degrees and push tibia posterior
-do this before lachman test to ensure integrity

60

posterolateral or posteromedial pain at extreme of flexion or extension is a

meniscal injury

61

anterior joint line tenderness and pain with squatting suggests

chondromalacia

62

McMurray test

meniscal damage
medial meniscus: extension + valgus + internal rotation
lateral: extension + varus + external rotation
+ if: palpable click, pain

63

MCL or LCL test

varus or vagus stress
determine laxity

64

pathophys of anterior knee pain

quadricep atrophy
crepitus with manipulation of patella

65

patellar apprehension test
patellar compression test

anterior knee pain
press inferiorly on superior patella: pain
hold patella and contract quad: pain

66

ottawa knee rules if 18 yo or older to determine if acute knee injury has fracture

get xray if any of following:
>55yo
tenderness at head of fibula
isolated patella tenderness
inability to flex to 90 deg
inability to bear weight immediately and in ED

67

confirmatory test for meniscal tear

MRI

68

refer for additional evaluation or surgery if:

hemarthrosis
ACL or meniscal tear
third degree collateral ligament injuries
severe functional impairment
poor response to conservative tx

69

treatment of knee pain

exercise

70

treatment of ACL

immobilization and then, surgery

71

treatment of meniscus tear

protected weight bearing + PT
if continues, surgery

72

treatment of DJD

glucosamine
CS injections
NOT NSAIDS - not inflammatory (unless acute flare)

73

treatment of collateral ligament tear

knee immobilizer, crutches until can tolerate walking

74

-focal area of bony tenderness

fracture