Knee Pain Complaint

Question 1

The greater the tearing of the ligament in a sprain the greater the what?

Answer 1

Blood loss and subsequent bruising

Question 2

What are sx of inflammation?

Answer 2

Pain and stiffness

Question 3

What are signs of inflammation?

Answer 3

Warmth, redness, swelling, pain to touch and pain with motion

Question 4

When taking the history on knee pain what should you look for when asking about what may have caused the pain?

Answer 4

Activity out of the ordinary like painting, cleaning or rearranging, traveling, playing with grandchildren, climbing ladders
Trauma such as falls, exercise/sports or MVAs

Question 5

Injury related knee pain

Answer 5

Definitive onset

Generally mono-articular and unilateral

Question 6

Non-injury related knee pain

Answer 6

Insidious or gradual
May be associated with constitutional sx, mono-articular or poly-articular, may be migratory
May change with activity and may have extra Articular signs

Question 7

What to ask for mechanism of injury?

Answer 7

What was the direction of the force? What did your joint do? What did it feel like at the time?
Was there any immediate swelling? Bruising?
Could you still use the joint?
How does it feel now?

Question 8

Describe what can be seen in a ligamentous disruption or fracture

Answer 8

Swelling is immediate or <2 hours

Unable to walk or bear weight

Question 9

Describe what is seen during a sprain or meniscus injury

Answer 9

Swelling appears >2 hours

Able to stand, walk, bear weight within a few minutes

Question 10

What is the sequence of assessing joint pain?

Answer 10

Gather history 
Point to the pain 
Mechanism of injury 
PE bilaterally (observation, palpation, ROM, extremity examination, special tests)

Question 11

What should you asses when evaluating ROM?

Answer 11

Passive and active ROM
Watch the pt for signs of pain (grimaces or hesitancy to move the joint)
Watch the joint for signs of asymmetric movement
Document the directions tested and how they were tested

Question 12

Describe internal/external rotation of the tibia

Answer 12

Knee flexed 90 degrees
Thumbs on each side of the tibial tuberosity grasping the calf
Induce internal/external rotation of the tibia on the femur
10 degrees in each direction
Compare bilaterally

Question 13

Fibular head motion is not a true what?

Answer 13

AP motion
It is slightly anterior-lateral and posterior-medial
~30 degrees

Question 14

What is unique about the fibula?

Answer 14

Unique motions

Only ligamentous attachments

Question 15

The fibular head glides anteriorly with what?

Answer 15

Foot pronation and posteriorly with supination

Question 16

What is crepitus?

Answer 16

A palpatory sensation of grinding during ROM

Question 17

How do you assess neurologic function?

Answer 17

Muscle strength, DTR and dermatomes bilaterally

Question 18

How do you assess for vascular function?

Answer 18

Pulse, capillary refill and edema bilaterally

Question 19

What is Osgood-Schlatter syndrome?

Answer 19

Traumatically induced apophyseal injury to the tibial tubercle in adolescents
Most common between ages 8-15
Bilateral in 30% of cases
Typically during a growth spurt

Question 20

Osgood-Schlatter syndrome commonly occurs with what?

Answer 20

Increase activities such as sports which causes micro trauma to the patellar ligament insertion onto the tibial tuberosity
Report of pain with climbing stairs or squatting

Question 21

How is osgood-schlatter diagnosed?

Answer 21

Point tenderness over the tibial tubercle
All other ligaments and structural testing is negative
Radiography unnecessary

Question 22

What are typical findings in OA pts?

Answer 22

Boney enlargement or deformity at the joint margins, genu varum deformity and stiffness lasting <30 mins
Crepitus is common

Question 23

What are the risk factors for OA?

Answer 23

Increasing age

Trauma, obesity, anatomic factors (varus and valgus deformities)

Question 24

What is OA?

Answer 24

Chronic inflammatory disease
Loss of articular cartilage
Osteophytes often appear at insertion site of tendons or ligaments
Soft tissue components react including thickening of joint capsule

Question 25

What is knee bursitis (housemaid’s knee)?

Answer 25

Chronic micro trauma from repetitive activity or pressure Presents with local swelling, tenderness, erythema and warmth Pain with AROM or compression (pre-patellar bursa) Must eliminate infectious etiology (systemic disease processes)

Question 26

What can be seen on PE for knee bursitis?

Answer 26

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

Question 27

How can pre-patellar bursitis be evaluated?

Answer 27

Aspiration of the bursa for cell count, C&2 and assess for crystals

Question 28

What is patellofemoral pain syndrome (chondromalacia patella)?

Answer 28

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)

Question 29

What is seen on the PE for patellofemoral pain syndrome?

Answer 29

Joint symmetry, rarely with effusion Address patella position within femoral groove as well as tracking with active ROM Crepitus under the patella with AROM and PROM +Patellar grind test Quadriceps weakness may be identified

Question 30

What is IT band syndrome?

Answer 30

Pain over the lateral aspect of the knee (above the joint line) May occur with increase in activity

Question 31

What is seen on the PE for IT band syndrome?

Answer 31

``` 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 32

What is patellar subluxation?

Answer 32

Dislocation which is a complete lack of contact between two articular surfaces

Question 33

How is the ACL injured?

Answer 33

By sudden rotation or hyperextension injury or direct hit | Positive anterior drawer and Lachman

Question 34

What is the etiology of ACL injury?

Answer 34

Contact injury: fixed lower leg with direct blow causing hyperextension or valgus deformation (less common) Non-contact injury: sudden deceleration with change in direction (more common)

Question 35

What is the classic presentation of ACL injury?

Answer 35

Sudden onset severe knee pain with large effusion developing within 2 hours typically from hemarthrosis Pt can report popping sensation or knee instability Can have associated injuries to other parts of the knee

Question 36

What is the etiology of meniscal injuries?

Answer 36

Acute meniscal tear: results from sudden change of direction in which the knee is twisted or rotated while the corresponding foot is planted Chronic: often from degenerative changes seen in older pts with minimal twisting injury history

Question 37

What is the classical presentation for meniscal injuries?

Answer 37

Slow onset knee pain with swelling or effusion developing over the next 24 hours Pts with untreated tears for weeks can report locking or catching of knee during extension

Question 38

What is the unhappy triad?

Answer 38

Injury of the ACL, MCL and medial meniscus | Foot planted, valgus deformity, rapid deceleration injury and rotation

Question 39

How are meniscal injuries diagnosed?

Answer 39

Often can be made clinically based on history and exam Medial or lateral joint line tenderness Positive McMurray’s test Knee MRI can confirm diagnosis

Question 40

Acute vs chronic meniscal injury

Answer 40

Generally hear a pop or snap at the time of the injury (acute >> chronic) Deep knee bending is painful or squatting Joint may pop or lock Often a loss of full extension Joint line tenderness on affected side Joint effusion present with acute > chronic

Question 41

Positive tests of meniscal injuries

Answer 41

``` Abnormal gait with decreased stance phase and knee extension on the symptomatic side Bounce home Joint line tenderness on affected side McMurray test Apley Grind ```