Approach to Knee Pain

Question 1

What direction does Fibular head move with foot pronation?

Answer 1

Anteriorly

Question 2

What direction does Fibular head move with foot supination?

Answer 2

Posteriorly

Question 3

What is crepitus

Answer 3

Palpatory sensation of “grinding” during range of motion.

Question 4

What is Osgood-Schlatter Disease/Syndrome?

Answer 4

Commonly occurs with increase activities such as sports—running, cutting, jumping—which causes microtrauma to the patellar ligament insertion onto the tibial tuberosity.
Most common between ages of 8-15

Question 5

How to test for Osgood-Schlatter Disease/Syndrome?

Answer 5

Point tenderness over the tibial tubercle
All other ligament and structural testing is negative
radiography unnecessary

Question 6

Signs of knee Osteoarthritis

Answer 6

Boney enlargement or deformity at the joint margins, genu varum deformity, and stiffness lasting ≤ 30 minutes are typical findings in OA
Crepitus is common.

Question 7

Risks of knee Osteoarthritis

Answer 7

Increasing age
Trauma
Obesity
Anatomic factors (Varus/valgus deformities)

Question 8

What is Housemaids Knee?

Answer 8

Bursitis of the knee
Chronic microtrauma from repetitive activity or pressure
Presents with local swelling, tenderness, erythema & warmth

Question 9

Signs of Knee Bursitis?

Answer 9

Redness (erythema) and swelling at the site of the bursa
Tenderness and warmth
Remaining exam: Ligaments intact

Question 10

What is Patellofemoral Pain Syndrome\Chondromalacia Patella?

Answer 10

Pain on or around the patella Insidious onset
Diffuse, aching, anterior knee pain
Can be unilateral or bilateral
Aggravated by climbing stairs, ascending hills, squatting or sitting for prolonged period of time (“theater sign”)
May have associated crepitus (grinding) with above activities

Question 11

How to test Patellofemoral Pain Syndrome?

Answer 11

Crepitus under the patella w/AROM & PROM

+ Patellar grind test

Question 12

What is Iliotibial Band Syndrome

Answer 12

Pain over the lateral aspect of the knee (above the joint line)

Question 13

How to test Iliotibial Band Syndrome ?

Answer 13

Appear symmetric
No warmth or erythema
Pain with palpation over the lateral femoral condyle
Normal ligamentous testing
Positive OBER’s test on effected side.
Assess Fibular head for dysfunction

Question 14

Patellar Subluxation (Dislocation) Test?

Answer 14

Apprehension test. They don’t want you to touch it

Question 15

ACL Tear test?

Answer 15

Anterior Drawer test / lachman test

Question 16

What causes ACL tear

Answer 16

Hyperextension or sudden rotation (valgus deformation)

Question 17

Symptoms of ACL tear?

Answer 17

Sudden onset severe knee pain with large effusion developing within 2 hours typically from hemarthrosis
Patient can report “popping sensation” or knee instability (giving out)
Can have associated injuries to meniscus, joint capsule, articular cartilage, subchondral bone (bone bruise), and other ligaments

Question 18

Meniscal Injuries symptoms?

Answer 18

Slow onset knee pain with swelling or effusion developing over the next 24 hours
Degree of pain related to severity of meniscal tear
Patients with untreated meniscal tears for weeks can report “locking” or “catching” of knee during extension
Others can report “popping” or “giving out” sensation or vague sense knee is not moving properly

Question 19

Unhappy Triad is what?

Answer 19

ACL, MCL, and MEdial meniscus

Question 20

How to test for meniscus?

Answer 20

McMurray Test and Apley Grind

Question 21

ROM of Knee Flexion?

Answer 21

145° - 150

Question 22

ROM of Knee extension?

Answer 22

0

Question 23

Patellar Reflex Documentation?

Answer 23

4+/4: Very brisk, hyperactive, with clonus
(rhythmic
oscillation between flexion and extension)
3+/4: Brisker than average, possibly but not
necessarily indicative of disease
2+/4: Average, normal
1+/4: Somewhat diminished, low normal
0/4: No response

Question 24

Patellar Reflex Nerve Root?

Answer 24

L4

Question 25

Popliteal Pulse Documentation?

Answer 25

+3 /: 3 Bounding +2 /3 : Average intensity, expected, normal +1 /3 : Diminished, barely palpable 0 /3 : Absent, not palpable

Question 26

Edema of foot documentation?

Answer 26

``` 0 : Abse nt 1+: Barely detectable, slight pitting (2m m); disappears rapidly 2+: Slight indentation (4 mm); 10 - 15 sec 3+: Deeper indentation (6 mm); >1 min 4+: Very marked indentation (8mm); 2 - 5 min ```

Question 27

How to do Valgus test?

Answer 27

Patient supine with the knee flexed to 30°. Physician supports the lower leg with one and other hand placed on the lateral aspect of the patient's knee. Apply a medial force to the proximal tibia while abducting the lower leg. This test is done at 30° flexion and neutral (0°).

Question 28

Valgus test indications?

Answer 28

(+) Test: Increased laxity, soft or absent endpoint, pain Indication: Medial collateral ligament (MCL) disruption If positive at 0° with knee fully extended, indicates more serious injury, possibly joint capsule

Question 29

How to do Varus test?

Answer 29

Patient supine with the knee flexed to 30°. Physician supports the lower leg with one and other hand placed on the medial aspect of the patient's knee. Apply a lateral force to the proximal tibia while adducting the lower leg. This test is done at 30° flexion and neutral (0°).

Question 30

Varus test indications?

Answer 30

(+) Test: Increased laxity, soft or absent endpoint, pain | Indication: Lateral collateral ligament (LCL) disruption

Question 31

How to do Anterior Drawer Test?

Answer 31

Patient supine with knee flexed to 90°. Examiner sits on the patient’s foot and grasps the proximal tibia with both hands, pulling the tibia anteriorly.

Question 32

Anterior Drawer Test indications?

Answer 32

(+) Test: Excessive translation Indication: ACL insufficiency (injury/tear) Lachman’s

Question 33

How to do Lachman's Test?

Answer 33

Patient supine. Examiner places cephalad hand on the distal thigh, superior to patella. Caudad hand grasps the proximal tibia. Flexing the knee to 10-30°, the examiner uses his caudad hand to pull the tibia anteriorly while the cephalad hand stabilizes the thigh.

Question 34

Lachman Test indications?

Answer 34

More sensitive test (+) Test: Increased laxity, soft or absent end point Indication: ACL insufficiency (injury/tear)

Question 35

How to do Posterior Drawer Test?

Answer 35

Patient supine with knee flexed to 90°. Examiner sits on the patient’s foot and grasps the proximal tibia with both hands, translating the tibia posteriorly.

Question 36

Indications of A Posterior Drawer Test?

Answer 36

(+) Test: Excessive translation Indication: PCL insufficiency, posterior capsular injury or disruption (injury/tear)

Question 37

How to do McMurrays Test?

Answer 37

Patient is supine, with hip and knee flexed. Examiner uses caudad hand to control the ankle and cephalad hand placed on distal femur. o Lateral Meniscus = Examiner rotates the tibia into internal rotation and applies a varus stress, then continues the leg into extension o Medial Meniscus = Examiner rotates the tibia into external rotation and applies a valgus stress, then continues the leg into extension

Question 38

Indications of McMurrays Test?

Answer 38

(+) Test: Pain or a palpable click during extension | Indication: Possible medial or lateral meniscus tear

Question 39

How to do Apley’s Grind Test- Compression test

Answer 39

Patient prone with knee flexed to 90°. Examiner uses downward force on the foot to provide a compressive force on the meniscus, while rotating the foot internally and externally

Question 40

Indications of Apley’s Grind Test- Compression test?

Answer 40

(+) Test: Pain with rotation and/or compression Indication: Possible meniscal injury, collateral ligament injury, or both

Question 41

How to do Apley’s Grind Test- Distraction test

Answer 41

Patient in same position as for the compression. Examiner stabilizes the thigh, then applies upward traction to the leg while rotating it

Question 42

Indications of Apley’s Grind Test- Distraction test

Answer 42

(+) Test: Pain with distraction and rotation o Increased ligamentous strain o Indication: Possible collateral ligament damage (+) Test: Relief of pain with distraction and rotation o Reduced meniscal pressure Indication: Possible meniscus injury

Question 43

How to do Patella-Femoral Grinding Test

Answer 43

Compress patella caudally into trochlear groove and | instruct patient to tighten quadriceps against resistance

Question 44

Indications of Patella-Femoral Grinding Test

Answer 44

(+) Test: Crepitus or pain Indication: roughness of articulating surfaces (ie: chondromalacia)

Question 45

How to do Bounce Home Test

Answer 45

Patient is supine, the patient’s heel is in the caudad hand of the examiner. With the knee completely flexed, the knee is passively allowed to extend. The knee should extend completely, or ‘bounce home’ into extension with a sharp end point.

Question 46

Indications of a Bounce Home Test

Answer 46

If extension is not complete or has a rubbery end fell, there is likely a torn meniscus and/or effusion.

Question 47

how to do a Bulge sign?

Answer 47

With knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, ‘milking’ the fluid downward.  Apply pressure on the medial aspect to force fluid laterally.  Tap the knee just behind the lateral margin with the opposite hand

Question 48

Indications of a Bulge sign?

Answer 48

A fluid wave toward the lateral aspect OR a bulge on | the medial side is positive for effusion

Question 49

If you hear a pop it is a sprain or strain?

Answer 49

Sprain

Question 50

How to do IT band Strech?

Answer 50

Pt prone Physician on contralateral side, Caudad hand holding ankle, Cephalad hand on lateral mid-thigh over IT Band Patient’s leg rotated lateral while simultaneously compressing the IT band and pulling posteriormedially into restrictive barrier

Question 51

How to do IR/ER tibia SD?

Answer 51

Seated, use foot to do MET with.

Question 52

How to treat Fibular head SD?

Answer 52

Use foot in supine/ pronation to act as long lever.