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Knee
Orthopedics
| Question | Answer |
|---|---|
| Tib/fib: which one is weight bearing? | Tibia |
| Knee Hx: | MOI ( twist, blow to knee, trauma); Pain; Instability, pops, clicks, grinding; swelling; pain hip/ ankle/ foot; prior |
| Inspection: Note: | contralateral joint (compare) |
| Immediate swelling: Big 4: | ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always) |
| Knee: DDx: Ant. Knee Pain | Patellofemoral dysfxn; Patellar tendinitis; Plica/ Fat Pad irritation |
| Knee: DDx: Medial | Meniscus, DJD, MCL; Pes Anserine Bursitis; Chondral lesion |
| Knee: DDx: Lateral | Meniscus, LCL, ITB; Posterolateral corner (PLC); Chondral lesion |
| Knee: DDx: Instability | ACL, PCL, PLC, ITB |
| Knee: DDx: Swelling ( immediate): | ACL, fx, dislocation, meniscus |
| Knee: DDx: Swelling (Intermittent) | Meniscus, gout, chondral lesions |
| Knee: DDx: Other | Infection, arthritis, referred pain, neoplasm |
| Knee PE: inspection | Swelling/Effusion (1+ to 3+ ; Local vs diffuse; Acute vs Chronic); Bruising; Deformity (fx; prior surg); Scars; Quad atrophy |
| Knee PE: Palpation: medial | Joint line (Menisc ); Condyle (Chondral lesion); Plica; Pes Ans bursa; MCL; Medial retinaculum (patella dislocn) |
| Knee PE: Palpation: lateral | Joint line (Menisc); LCL; Iliotibial Band (Gerdy tub.; Bursa); Condyle (Chondral lesion; Patella dislocation); Femoral head (Peroneal n. Sx); PLC (posterior) |
| Knee PE: Palpation: posterior | Bakers cyst (Menisc); Meniscus tears; Poplit art; Poplit mx; Gastrocnemius tear; Hamstring tear (distal) |
| Knee PE: ROM | Flexion (135-140; goniometer); ext 0 degree (some: 5-10 degree natl hypertext); cf to nml knee; Squat (ltd ? Menisc tear) |
| Patella Tests | Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness) |
| Q angle | angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl |
| Medial knee tests | MCL or Valgus; McMurray; |
| MCL or Valgus test | O & 20-30 degrees flexion |
| MCL or Valgus test: instability at 0 degrees = | Concomitant ACL |
| MCL or Valgus test: Concomitant ACL Grade I = | no opening, but pain |
| MCL or Valgus test: Concomitant ACL Grade II = | opening with endpoint |
| MCL or Valgus test: Concomitant ACL Grade III = | no endpoint |
| McMurray test: sensitivity = | Only 65% |
| McMurray test: medial (ME) = | Ext rotation w/ flexion & valgus |
| McMurray test: lateral | Internal rotation w/ flexion & varus |
| McMurray test: true positive = | A click (not pain) |
| McMurray test: Apleys compression = | Not usually helpful |
| Lateral knee tests | Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial |
| Lateral knee tests: Varus testing for LCL: grading = | Same grade as for MCL |
| IT Band tests | Obers; Nobles compression test |
| Obers | Inability for Up Leg to go down to table (= tight lateral structures) |
| Nobles compression test | Pain over lat. Fem condyle at 20 deg knee flexion |
| PLC injury usu occurs: | in ACL and/ or multi-ligament knee injuries |
| PLC tests | Recurvatum (with PCL); dial test at 30 degrees flexion; reverse pivot shift |
| ACL Tests | Lachman; ant drawer (unreliable); Pivot shift (difficult) |
| ACL Tests: gold std = | Lachman |
| PCL Tests | Post drawer & recurvatum; sag sign; quad active; dial test at 90 degrees flexion |
| PCL Tests: problem w/ dx | easily missed or mistaken for ACLs (Hx important) |
| PCL Tests: Posterior drawer | Much better than ant. drawer |
| Knee Films | AP, Lateral; Merchant; Tunnel view (look for OCD) |
| Knee Films: AP/ Lateral | Tumors; Fx; DJD; Surgeries/ Hardware |
| Knee Films: Merchant | Patella (Instability; DJD; Chondral lesions) |
| Knee DJD: Fairbanks Changes | Flattened Tib. plateau; cec. joint space; Osteophytes; Subchondral cysts |
| MRI: excellent for: | soft tissue |
| MRI in ortho: for: | ACL ( >95%); Menisc (>85%); chondral lesion (cannot quantify size); MCL,LCL,PLC,PCL; Bone Contusions/ Edema; tumors; fx? |
| CT: excellent for: | fracture characterization |
| CT: not good for: | evaluating soft tissue injuries |
| Quad active test: | When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags |
| Recurvatum test: | Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee) |
| Lachman test: | At 20 degrees flexion; stabilize femur, pull up on tibia |
| Ant drawer test: | knee is flexed to 90, then pull on tibia |
| Thomas test: | If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat |
| MCL: typical Hx: | Valgus injury (Soccer, ice hockey) |
| Most common lig. Tear = | MCL |
| MCL: PE: | Medial pain (on joint line, above & below); Grade I,II,III; Valgus stress |
| MCL: Tx: | conservative; NSAIDs; Ice; Rest; Bracing; PT; RTP?; Surgical: Rare |
| MCL: Tx: RTP (Gr I,II): | symptomatic tx |
| MCL: Tx: RTP (Gr III): | 4-6 weeks, start in extension |
| Medial Meniscus Tear: Hx | Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching |
| Medial Meniscus Tear: PE: | MJL tenderness; McMurray; Apley; Cyst |
| Medial Meniscus Tear: Tx: | conservative vs surgical |
| OCD = | Osteochondritis Dissecans |
| OCD & Chondral Defects: Hx: | Intermittent swelling after exercise, locking, catching, vague pain |
| OCD & Chondral Defects: PE: | small effusion, TTP MFC or LFC |
| OCD & Chondral Defects: Tx: | NWB, progress slowly over 6 weeks or more |
| Plica Syndrome: Hx: | snapping, esp with squats (can also be MMT) |
| Plica Syndrome: PE: | palpable plica, localized swelling; Imaging (r/o other injuries) |
| Plica Syndrome: Tx: | PT, ice post exercise; iontophoresis; NSAIDs; Injection; Surgical excision |
| Lateral Knee Pain: DDx | Lat Meniscus Tear; LCL Tear; IT Band; Patella disloc/ subluxation; PLC; OCD; Hamstring strain/ tear; PFSS |
| ITB Syndrome AKA | Runners Knee |
| ITB Syndrome Sx | Snapping knee or hip; Occasional instability |
| ITB Syndrome: Look at: | biomechanics, flexibility; Mileage |
| ITB Syndrome: Tx: | PT, local distal injection, orthotics, different shoes or surfaces |
| LCL Tear = type of injury | Varus injury (do varus stress test) |
| LCL Tear: Varus test Grade I-II: | conservative; 1-2 wks(I), 4-6 wks (II) |
| LCL Tear: Varus test Grade III: | consider surgical repair/ reconstruction; assess for concomitant injuries (PLC) |
| Patellar Dislocation: Hx: | visual sublux/ dislocation, twisting motion; previous occurrence? Brace? N/V status |
| Patellar Dislocation: PE: | Ant Knee exam; biomechanics |
| Patellar Dislocation: Radiographs: | AP/Lat, Merchant view |
| Patellar Dislocation: Tx: | extension brace 1-2 wks; quad strengthening; RTP w/ buttress brace |
| Patellar Dislocation: Tx: If multiple: | consider surgical repair |
| ACL Tx | Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace |
| ACL: dx tests | MRI to R/O other injuries |
| ACL: recovery time if reconstructed: | 9-12 mos |
| PCL Injuries: tests | Posterior drawer; sag sign; Recurvatum; Quad active test |
| Theater sign | seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain. |
| PFD Tx | PT; Short course of NSAIDs; open patella brace optional; footwear/ orthotics ; modify activity; Surgery (Last Resort) |
| PFS: Tx: PT for: | VMO (vastus medialis obliqus) (co-contract with adductors); hip abductors/ ext rotators |
| Hemarthrosis | usually due to injury (most common ACL), rapid effusion (2-4 hrs) |
| most common cause of knee pain in pts <45 yo = | PFPS; esp women |
| young pt w/ant knee pain worse w/repetitious flexion & without clear alternative cause: | PFPS |
| Local TTP, pain on motion and at rest; occasional loss of active movement; swelling, erythema, warmth: | bursitis (inflammation of synovial membrane over bony prominences) |
| Most common knee injuries | medial: anserine bursitis; MCL (most common lig); medial meniscus (most vulnerable) |
| 2nd most common knee pain site | anterior: PFPS; prepatellar bursitis; OSD; inflam arthritis |
| least common knee pain site | lateral: lat meniscus; ITB |
| Diffuse anterior knee pain w/ swelling & inflammatory change = | inflammatory arthritis (RA, gout, pseudogout) or septic arthritis |
| meniscus tear dx made by: | MRI or diagnostic arthroscopy |
| Lachman test assesses: | anterior-to-posterior laxity |
| McMurray test: | rotate foot outward to test medial meniscus; inward to test lateral; + is painful click |
| Knee pain DDx | OA, effusion, pop cyst, bursitis, ACL/coll lig, meniscus tear, PFPS, ITB, stress fx injury to ACL/PCL, meniscus, PF syndrome, bursitis, OSD, ITB, baker cyst, OA, RA |
| tests for suspected (knee & hip) OA | ESR, RF, synovial fluid analysis, imaging |
| Large joint pain. Knees w/ medial joint space narrowing, osteophytes. No erythema or warmth | Osteoarthritis (tx acetaminophen) |
| Tibial pain after running (military recruits), athletic activity (running sports) | Shin splints, stress fracture. Get bone scan if negative x-ray |
| Noncontact knee injury; pop; pivoting stress | ACL (Lachman / ant drawer test) |
| 8 – 10yo male with limp, knee pain | Legg-Calve-Perthes Disease |
| 12 – 15yo overweight male knee pain, limp, hip pain (knee XR normal) | SCFE |
| Adolescent male with knee pain, tenderness over tibial tuberosity | Osgood-schlatter disease |
| Retropatellar knee pain esp. in females | Patellofemoral pain syndrome – increased Q angle, strengthen quadriceps |
| Degenerative area at proximal end of patellar tendon | patellar tendonopathy (must distinguish from osgood schlatter) |
| Sudden pop with plantarflexion (& Pain with active plantarflexion but strength intact) = | Medial gastrocnemius tear (RICE, no surgery) |
| bucket handle tear | meniscus tear (McMurray may reduce); tx arthroscopic repair or debridement (conservative tx not helpful) |
| Tib/fib: which one is weight bearing? | Tibia |
| Immediate swelling: Big 4: | ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always); Within first few hrs: Hemarthrosis |
| Patella Tests | Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness) |
| Q angle | angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl |
| Medial knee tests | MCL or Valgus; McMurray |
| MCL or Valgus test | O & 20-30 degrees flexion |
| MCL or Valgus test: instability at 0 degrees = | Concomitant ACL |
| MCL or Valgus test: Concomitant ACL Grade I = | no opening, but pain |
| MCL or Valgus test: Concomitant ACL Grade II = | opening with endpoint |
| MCL or Valgus test: Concomitant ACL Grade III = | no endpoint |
| Lateral knee tests | Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial |
| IT Band tests | Obers; Nobles compression test |
| Nobles compression test | Pain over lat. Fem condyle at 20 deg knee flexion |
| ACL Tests | Lachman; ant drawer (unreliable); Pivot shift (difficult) |
| ACL Tests: gold std = | Lachman |
| PCL Tests | Post drawer & recurvatum; sag sign; quad active; dial test at 90 degrees flexion |
| Quad active test: | When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags |
| Recurvatum test: | Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee) |
| Lachman test: | At 20 degrees flexion; stabilize femur, pull up on tibia |
| Ant drawer test: | knee is flexed to 90, then pull on tibia |
| Thomas test: | If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat |
| Most common lig. Tear = | MCL |
| Medial Meniscus Tear: Hx | Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching |
| OCD = | Osteochondritis Dissecans |
| OCD & Chondral Defects: Hx: | Intermittent swelling after exercise, locking, catching, vague pain |
| OCD & Chondral Defects: PE: | small effusion, TTP MFC or LFC |
| Plica Syndrome: Hx: | snapping, esp with squats (can also be MMT) |
| ACL Tx | Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace |
| ACL: recovery time if reconstructed: | 9-12 mos |
| PCL Injuries: tests | Posterior drawer; sag sign; Recurvatum; Quad active test |
| Theater sign | seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain |
| Dx given to pt who present w/traumatic knee effusion, until proven otherwise | ACL tear |
| possible graft choices in an ACL repair | bone-patellar tendon-bone, hamstring autograft, cadaver allograft |
Created by:
Abarnard
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