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MSK Practical Exam > Knee > Flashcards

Knee Flashcards

1
Q

What percentage of knee injuries are ligament injuries?

A

40%

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2
Q

What percentage of ligament knee injuries are ACL?

A

50%

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3
Q

What healing capacity has the ACL got and why?

A

Poor due to its limited blood supply

Cant repair itself

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4
Q

Why are the ACL injury rates higher for females compared to males?

A

Increased Q angles

Ligaments have greater laxity

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5
Q

What is the origin and insertion of the ACL and its direction?

A

Origin: Antero-medial intercondylar area of tibia

Insertion: Posterior lateral femoral condyle

Direction: From tibia goes laterally and posteriorly (30 degree angle)

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6
Q

What are the 2 bundles of the ACL?

A
  1. Antero-medial bundle - taut at full flexion

2. Postero-lateral bundle - taut at full extension

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7
Q

What are the main function of the ACL

A

Reduces anterior tibial translation

Restricts foot abduction and hyperextension of the tibia

Limiting knee IR

Proprioceptive feedback

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8
Q

After ACL reconstruction surgery, what do people struggle with the most?

A

Proprioception

ACL loses its proprioceptive fibres

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9
Q

What are the subjective signs of an ACL rupture

A

Popping sensation

Traumatic knee injury

Instability and giving way - secondary to pain, eccentric loading of the knee (going downstairs)

Joint pain

Haemarthrosis

Mechanism of injury - non-contact, pivot, hyperextension, landing in extension, foot planted, valgus collapse

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10
Q

What is the mechanism of an ACL injury?

A

Non-contact

Pivot

Hyperextension

Landing in extension

One step-stop deceleration

Can be contact - tackling from behind (side), valgus collapse

Describe that they cant anticipate the event or loss of concentration

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11
Q

Explain valgus collapse

A

Fixed foot and patient goes to change direction

Ankle eversion

Knee abduction (distal tibia goes away from the midline)

Femoral adduction

Forced medial opening of the knee

30 degree knee flexion

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12
Q

Name the special tests for the ACL

A

Lachmans

Anterior Draw

Prone Lachman’s

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13
Q

What has the literature stated regarding the sensitivity of diagnosing an ACL injury?

A

If you get a good subjective information and objective information = almost 100% sensitivity

Mostly done on the chronic stage of injury

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14
Q

What is the best test for acute ACL injuries?

A

Lachmans = High sens, high spec and high intra-tester reliability

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15
Q

What is the best test for chronic ACL injuries?

A

Anterior drawer = high sens and high spec

Lachmans also has high sens, high spec and intra-tester reliability

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16
Q

How do you grade ACL laxity?

A

1 (1mm to 5mm)
2 (6mm to 10mm)
3 (>10mm)

Difficult to feel the difference

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17
Q

What type of physio is the anterior drawer good for?

A

Inexperienced physios

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18
Q

Why should you not do the pivot shift test?

A

Can make patients nauseas and they do not like it

Brutal test usually used by surgeons when patients are under anaesthetic

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19
Q

What type of patient is the prone lachmans good for?

A

Large patients

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20
Q

Should you use imaging for ACL injuries?

A

Alot of joint line pain = x-ray to rule out bony injuries

MRI has similar diagnostic accuracy to good subjective and objective assessment

MRI before surgery

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21
Q

What is the most common knee pathology?

A

NICE 2014

Knee OA

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22
Q

How do you diagnose knee OA?

A

Diagnosis of exclusion - cant find a pathology then send patient for an x-ray

X-ray would confirm knee OA through the Kellgren & Lawrence classification

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23
Q

What is the Kellgren & Lawrence classification?

A

How to diagnose and grade Knee OA on an x-ray

Joint space narrowing, osteophytes, sclerosis and bone end deformity

Grade 0 - None

Grade 1 Doubtful

Grade 2 Minimal

Grade 3 Moderate

Grade 4 Severe

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24
Q

What is the problems with x-ray and knee OA?

A

Poor correlation between imaging and pain experience

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25
Q

What is knee OA symptoms, level of pain and level of disability potentially linked to?

A

Psychosocial factors and central sensitisation

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26
Q

How can you diagnose someone with knee OA?

A

NICE 2014 Guidelines

Atraumatic knee pain

Activity related joint pain and

> 45 years old and

Morning joint-related stiffness that does not last longer than 30 minutes

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27
Q

How can you manage someone with knee OA with yellow flags?

A

Reassure that the person does not need an x-ray and how these poorly correlate with pain experience

Educate how increasing strength and balance can reduce pain

Encourage patient to be as active as possible

If conservative management does not work = x-ray to confirm

Just get an x-ray if patient is so anxious and it will help management

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28
Q

What is a patient reported outcome measure for knee OA?

A

WOMAC

3 Parts - Pain, stiffness and function

high sens and high sens

Pain and stiffness have high ceiling effects but function has low ceiling effect

Low ceiling effect = cant measure higher levels of function

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29
Q

What are the subjective indicators of PFPS?

A

Nunes et al 2013/Cook et al 2012

Diagnosed through exclusion

Pain during squatting - high sens, moderate spec (most useful

Pain during stair climbing - good sens, moderate spec

Pain during prolonged sitting or flexion - good sens, moderate spec

Pain location - U Shape <5 years

Usual bilateral pain - biomechanics or central sensitisation?

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30
Q

What are the special tests for PFPS?

A

Clarke’s sign - good spec, low sens

Apprehension test - also used to assess patella dislocation

Patellar tilt - high spec, low sens

31
Q

What is a positive patellar apprehension test?

A

Patient become apprehensive or feels a sensation of the patella going to dislocate

Patient may activate quads to stop movement of the patella

Laxity alone = not a positive test

Good spec for patella dislocation

32
Q

What force do you apply to the patella with Clarkes sign?

A

Compression and distal - then ask patient to contract quads

33
Q

What other functional movements may someone with PFPS find painful?

A

Running

Hopping

Pain with step down

34
Q

What muscles are important with PFPS?

A

Hip musculature

Weak glutes = IR of Femur = lateral mal-tracking of the patella

35
Q

Why is PFPS multifactorial?

A

Weakness of hip musculature (Glutes), knee musculature (quads/hamstrings) and poor foot biomechanics (weak tib post)

Medial collapse

36
Q

Explain the anatomy of the meniscus

A

Fibro-cartilaginous plates that sit on top of the tibial plateau

Medial and lateral

Medial is more stretched out C-shaped

Lateral is more rounded C-shaped with larger surface area

Attached together by the transverse ligament

Attached to the tibia plateaus by the coronary ligaments

Thick peripheral border and attaches to the joint capsule

Divided into the anterior horn, body and posterior horn

37
Q

Which of the menisci get injured (50%) with an ACL injury and why?

A

Medial meniscus - close to the origin of the ACL

38
Q

What ligament fuses with the medial meniscus?

A

Deep fibres of the MCL

Commonly injured together

39
Q

Explain the blood and nerve supply of the menisci

A

Poor blood supply - only periphery and horns are vascular

Nerve supply is the same as the vascular supply (periphery and horns)

40
Q

Where does the menisci get there main source of nutrition from and what is the implication for this?

A

Synovial fluid

Takes the meniscus a long time to heal

41
Q

Where are mechanoreceptors found in the meniscus?

A

Horns = proprioceptive feedback and joint position sense

42
Q

What are the subjective indicators of a meniscal tear?

A

Logerstedt et al., 2018; Nie et al., 2011

Mechanism of injury:
Twisting injury with foot planted - weight bearing
Traumatic
Tearing sensation at time of injury

Symptoms:
Localised pain - patient will point to specific area, usually the joint line
Delayed effusion (6-24 hours post injury)
Clicking
Catching or locking
Feeling of giving way - Associated with pain

Pain with forced knee hyperextension - Anterior Horn

Pain with forced max knee flexion - Posterior Horn

43
Q

How do you differentiate between an isolated meniscus injury and a meniscus injury with ACL injury?

A

Rate of swelling

44
Q

What is it important not to do when asking about patients symptoms especially with potential meniscus injuries?

A

Do not lead the patient - try and get them to describe as many symptoms as they can

Meniscus symptoms can be similar to non-specific knee pain and other knee injuries

45
Q

What are the special tests for meniscal injuries?

A

Joint line tenderness

McMurrays

Apleys

Thessalys

46
Q

How accurate is special tests for diagnosing meniscal injuries?

A

Hegedus et al., 2017

Joint line tenderness, McMurrays or Apleys alone are not accurate to diagnose meniscal tears

Specificity generally better than sensitivity for all 3 tests

Joint line tenderness has the best sens and spec but can get a lot of false positives

47
Q

What are the advantages and disadvantages of the Thessaly test?

A

Advantages - Function

Disadvantages - cant standardise the degree of knee flex and amount of rotation

High Spec but moderate sens

48
Q

How should you order the special tests for meniscal injuries and why?

A
  1. Joint line tenderness
  2. McMurrays
  3. Thessalys

At least 2 are positive = meniscal tear likely

At least 2 are negative = meniscal tear unlikely

Irritability

49
Q

What are the limitations of meniscal testing?

A

Variations in the literature for what is a -ve and +ve test

Tests done in a variety of different ways and this isnt described in the literature

Literature is of poor methodological quality and have high bias

50
Q

Why are there limitations to meniscus testing?

A

Due to the variety of tears

51
Q

What are the different types of meniscus tears?

A

Bucket handle tear

Radial tear

Parrots beak tear

Horizontal tear

Root tear

Degenerative tear

52
Q

What causes degenerative meniscus tears?

A

General wear and tear e.g. walking, hereditary, footwear, occupations that involve patients kneeling a lot (plumbers)

53
Q

What type of meniscus tear will you get a true locking and a positive test for all special tests?

A

Bucket handle tear

54
Q

Where in the meniscus could a patient get a tear but not get any symptoms and why?

A

Centrally (radial tear) as there is no nerve supply

Although this may not heal due to poor vascular supply

55
Q

Why may a patient get symptoms if the tear is in the area of the meniscus with no nerve supply?

A

Scan that shows tear = patient becomes anxious = increase in pain

56
Q

When should you image a meniscus tear?

A

Bucket handle tears as they require surgery (true locking)

NICE guidelines?

57
Q

Why does lateral meniscus tear injuries cause more symptoms and take longer to heal?

A

More load goes down through the lateral meniscus (70%) = more pressure

The lateral joint surface does not come together very well compared to the medial joint surface

Less surface area = more pressure

58
Q

What is the anatomy of the medial collateral ligament (MCL)?

A

2 components

Superficial fibres
Superior to inferior
As the fibres go over the medial joint line it spreads out

Deep capsular fibres is continuous with the medial meniscus

If meniscus is injured means that the deep capsular fibres are involved

Bursa between superficial and deep fibres

59
Q

What is the function of the MCL

A

Primary medial knee stabiliser

Limit valgus stress

60
Q

Which hamstring is connected with the MCL, how and why is this important?

A

Semimebranosus tendon fuses with the superficial fibres of the MCL

Injury to one of these structures usually causes injury to the other

Semimem tendon injury e.g. tendinopathy

61
Q

What is the mechanism of injury of an MCL injury?

A

Foot planted

Valgus knee loading

External rotation or. combined cutting movement that opens the joint

Usually accompanied with an external force (how to differentiate from an ACL injury)

62
Q

In football when do most MCL injuries occur?

A

Last 10 mins

Strong association with fatigue - hamstrings

63
Q

How you diagnose an MCL injury?

A 
History
Trauma by external force to the leg
Rotational trauma
Valgus knee loading
Planted foot

Physical exam
Laxity and pain with valgus stress test 30 degrees knee flexion

This combined method has moderate sens and high spec

64
Q

At what knee angles do you test for the valgus stress test and why?

A

0 degrees - laxity and pain means an ACL injury

30 degrees - laxity and pain means an MCL injury

Laxity and pain on both = ACL and MCL injury

65
Q

What is the anatomy of the PCL?

A

More vertical than the ACL and posterior of the midline

PCL has a lot of surrounding support that the ACL does not have

Goes beyond the joint capsule

2 components
Anterior-lateral
Posterior-medial

66
Q

What are the signs and symptoms of a PCL injury?

A

95% of people with PCL injuries will have associated injuries

Vague, non-specific symptoms e.g. discomfort that is difficult to isloate

Mild/mod non-specific pain posterior knee (especially when squatting/kneeling/going downstairs)

Instability

67
Q

What is the mechanism for a PCL injury?

A

Anterior tibial blow injury with knee slightly flexed (dashboard injury)

Fall on flexed knee with foot in PF

Violent hyperextension of the knee joint

68
Q

What are the special tests for the PCL?

A

Posterior drawer test

Sag sign
Variety sens and poor data on spec

69
Q

What are the key elements of performing the posterior drawer test?

A

Need to bring tibia as far forward as possible - if person has no PCL the tibia will sag = false negative

ACL rupture could give you a false positive

Iso quad contraction during this test will move the tibia anteriorly = sucking sound and see tibia relocating

Can support patient in 90 degrees knee and hip flexion to use gravity to increase the sag

Variety sens and poor data on spec

70
Q

What is the anatomy of the Lateral collateral ligament?

A

Shorter than the MCL

Cord like

Slants posteriorly from lateral epicondyle to the head of the fibula

Seperated from the lateral meniscus by the popliteus

Surrounded by tendon of the bicep femoris

Tightens in full extension

Stops varus, rotation in full extension

71
Q

What are the signs and symptoms of a LCL injury?

A

Usually combined with more extensive damage

May get an arcuate fracture = avulsion fracture of the head of the fibula

72
Q

What is the objective examination for a LCL injury?

A

Palpation of the head of the fibula to rule out an arcuate fracture

Varus stress test
No research

73
Q

At what angles of the knee should you do the varus stress test?

A

0 degrees = to test the PCL

30 degrees = to test the LCL

Pain and laxity for both = LCL and PCL are injured

MSK Practical Exam (11 decks)

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