Lecture 11: Knee, Ankle, and Foot Complaint

Question 1

What does a “locking” sensation of the knee suggest?

Answer 1

Meniscal Tear

Question 2

What does a “popping” sensation of the knee suggest?

Answer 2

Ligamentous tear or rupture

Question 3

What does a “giving out” sensation of the knee suggest?

Answer 3

Ligamentous rupture or patellar subluxation

Question 4

What does a rapid onset of large, tense knee effusion suggest?

Answer 4

-within two hours of injury

ACL rupture or tibial platear fracture

Question 5

What does a slower onset of moderate knee effusion suggest?

Answer 5

24-36 hours of injury

Meniscal tear or ligamentous sprain

Question 6

What does a recurrent knee effusion suggest?

Answer 6

Meniscal tear

Question 7

What are different techniques to palpate for effusions?

Answer 7

Milking Techniques: Stroke down knee

Medial Pressure: Apply pressure to medial aspect of knee to look for lateral bulging

Fluid Wave Technique: Tap lateral knee and feel for fluid wave

Question 8

What does a Valgus knee stress test for?

What does a Varus knee stress test for?

Answer 8

Valgus: MCL injury

Varus: LCL injury

Question 9

What does an Anterior Drawer test indiacte?

What does an Posterior Drawer test indiacte?

Answer 9

ACL and PCL Injury

Question 10

What does a McMurray’s test indicate?

Answer 10

Medial or lateral meniscal tear

Question 11

What does the Ottawa Knee Rule encompass?

Answer 11

• IT IS SHOULD YOU DO AN XRAY OR NOT: IF YOU HAVE ONE OF THESE THEN YOU SHOULD DO IT
• Age is 55 years or over
• Inability to bear weight for four steps immediately after injury or in emergency setting
• Inability to flex knee to 90^o
• Tenderness over head of fibular or isolated to patella

Question 12

When should you obtain a knee x-ray after an acute knee injury?

Answer 12

If the patient fits one of the Ottawa Knee Rule criteria

Question 13

ACL injury:

contact vs non contact injury

presentation

Answer 13

• contact: fixed lower leg with a direct blow causing hypereexension or valgus deformation
• non contact injur: sudden decelleration with change of direction
• presents with: LARGE EFFUSION and has popping seanstion/ giving out
• can lead to OA in 10-20 years after the inital injury

Question 14

What is a meniscal injury?

Acute vs chronic

presentation:

Answer 14

Dx: Medial or lateral joint line tenderness

Acute: •Results from a sudden change of direction in which the knee is twisted or rotated while the corresponding foot is planted

Chronic: degenerative changes seen in older patients with minimal twisting injury history

Presentaiton:

–Patients with untreated meniscal tears for weeks can report “locking” or “catching” of knee during extension

-can treat with RICE

Question 15

What is Patellofemoral Pain Syndrome?

Answer 15

Anterior Knee Pain: most common reason why people come in for knee pain for ppl under 60 years

• ​Pain under patella
• Worsens when climbing up or down the stairs and prolonged sitting (movie gower sign)
• Dx: Pain with squatting
• Treat hip and quadriceps with PT

Question 16

What is Osgood-Schlatter Disease?

Answer 16

Tibial Apophysitis

• Anterior knee pain seen often in children ages 9-14 with a rapid growth spurt
  
  • Tenderness of bony prominence over tibial tuberosity
• Chronic avulsion of the secondary ossification center (apophysis) of the tibial tuberosity
• -kids describe it as a low grade ache to a pain that causes a limp

Question 17

What is Pes Anserinus Pain Syndrome?

Answer 17

Medial Knee Pain

• Worsened with repetive flexion and extension
• Risk Factors: Diabetes, Female, Obesity
• Pain worse at night
• usually from reffered mechanical knee pain or true bursisits

Question 18

What is Iliotibial Band Syndrome?

Answer 18

Knee Pain

• Common knee pain, especially in runners or cyclists
  
  • Intermittent sharp pain that can progress to constant, deep pain
• Noble Test can detect
• Tx: IT band strenching

Question 19

What is Popliteal Cyst (Baker’s Cyst)?

Answer 19

Bursa

• Mostly asymptomatic and an incidental finding
  
  • Can present with posterior knee pain, knee stiffness, or mass behind knee
• Foucher’s Sign: cyst softens or disappears with knees flexed to 45^o

Question 20

What does a Talar Tilt test indicate?

Answer 20

Lateral Ankle Sprain

Calcaneofibular Ligament Sprian

Anterior Tabofibular Ligament Injury

Question 21

What does an ankle Anterior Drawer Test for?

Answer 21

Lateral Ankle sprain

Question 22

What does an eversion ankle test for?

Answer 22

Medial Ankle Sprain

Deltoid Ligament Injury

Question 23

What does a squeeze test indicate?

Answer 23

High Ankle Sprain

Distal Tibiofibular Syndesmosis Injury

Question 24

What does Homan’s Sign test for?

Answer 24

DVT

Question 25

What is Plantar Fasciitis?

Answer 25

**Foot Pain** * Very common foot pain in adults * Overuse can cause microtears in plantar fascia, resuliting in degeneration of fibrous tissue or acute inflammation * Presents as sharp, stabbing, medial, plantar heel pain * _Risk Factors:_ Running, obesity, flat feet, high-arched feet * **Tenderness to palpation over _medial plantar calcaneal region_** * **Pain worse with passive dorsiflexion**

Question 26

What is the most common ankle sprain?

Answer 26

Lateral Ankle Sprain

Question 27

What other injuries do you see with lateral ankle sprain?

Answer 27

Lateral ankle ligaments (e.g. anterior talofibular and calcaneofibular ligaments) injury secondary to _foot inversion_ and _plantar flexion_ _-dx by: anterior drawer test or talar tilt test_

Question 28

What other injuries do you see with medial ankle sprain? Is the foot everted or inverted?

Answer 28

Medial ankle ligaments (e.g. deltoid ligament complex) injury secondary to forced _eversion_ _-dx by eversion test_

Question 29

What other injuries do you see with syndesmotic sprain?

Answer 29

Distal Tibiofibular Syndesmosis Injury: high ankle sprain _Foot eversion_ with external rotation and/ or _Dorsiflexion_ _-dx by squeeze test_

Question 30

How does the Ottawa Rules apply to the ankle?

Answer 30

**X-rays Performed if:** * Tenderness over medial or lateral malleolus * Inability to bear weight immediately after injury * Tenderness over base of 5^th metatarsal or navicular

Question 31

What joint is most likely to experience a gout flare? What is a gout flare? How is it dx?

Answer 31

1^st metatarsophalangeal joint - precipitation of MSU crystals - athrosentesis: and negative bifrigent needle shaped cyrstals on polarized light

Question 32

What is a nobel test?

Answer 32

patient in lateral decubitis position with knee passivley flexed to 60 degreee -positive test if TTP over the latearl femroal epicondyle during the maneuver