Knee Lecture

Question 1

Possible remote/serious knee pathology

Answer 1

• Patella or Tibial Plateau Fracture (OKR)
• DVT
• Osteochondritis Dissecans
• Lyme disease
• Compartment syndrome
• Syphilis
• Septic arthritis
• Gout
• Popliteal Cyst (Baker’s Cyst)

Question 2

Ottawa Knee Rules to send of an X-ray

Answer 2

• Age >55
• Isolated tenderness of patella (no other knee bone tenderness)
• Tenderness of the head of the fibula
• Inability to flex knee >90º
• Inability to WB both immediately & in the ED regardless of limping

Question 3

What are the 6 P’s of compartment syndrome

Answer 3

• Pain
• Palpable tenderness
• Paresthesia
• Paresis
• Pallor
• Pulselessness

Question 4

Illness script for compartment syndrome

Answer 4

• 6 P’s
• Acute usually due to trauma
• Pain with passive stretch
• Symptom emergency
• Typically runners, soccer players, and in the anterior compartment
• Key sx: pain out of proportion to clinical situation is usually first Sx

Question 5

Describe primary versus secondary type of Syphilis arthritis

Answer 5

• Syphilis is a STI (soft tissue infection)
• Primary: single sore (mouth or genitals)
• Secondary: rash/sores not in the above areas; fever/sore throat; muscle aches & joint pain; synovitis
• Need medical treatment to prevent dementia & paralysis

Question 6

Describe Herpes Gladiatorum

Answer 6

• High risk = athletes with close contact (ex: rugby & wrestling)
• Person to person contact
• Equipment to person contact

Question 7

Other soft tissue infections

Answer 7

• Bacterial skin & soft tissue infections
• Tinea gladiatorum
• Varicella zoster virus
• Scabies

Question 8

Illness script for Osteochondirtis dissecans

Answer 8

• Mostly in children & adolescents
• Segment of bone cracks & loosens away resulting in loosening of cartilage as well
• Disruption of blood supply possibly from repetitive jumping/loading
• Treatment: relative rest mostly and Sx modification

Question 9

Possibilities for medial knee pain

Answer 9

• Medial collateral ligament sprain
• Medial meniscal tear
• Pes anserine bursitis
• Medial plica syndrome

Question 10

Possibilities for anterior knee pain

Answer 10

• Patellar subluxation or dislocation
• Tibial apophysitis (Osgood-Schlatter lesion)
• Jumper’s knee (patellar tendonitis)
• Patellofemoral pain syndrome (chondromalacia patellae)

Question 11

Possibilities for lateral knee pain

Answer 11

• Lateral collateral ligament sprain
• Lateral meniscal tear
• Iliotibial band tendonitis

Question 12

Possibilities for posterior knee pain

Answer 12

• Popliteal cyst (Baker’s cyst)
• Posterior cruciate ligament injury

Question 13

How do you classify Patellofemoral Pain Syndrome

Answer 13

• Presence of retrropatellar or peripatellar pain AND
• Repoduction of etropatellar or peripatellar pain with squatting, sitting, stair climbing or other functional activities that load the PF joint in a flexed position AND
• Exclusion of other conditions that may cause anterior knee pain

Question 14

Describe Zohler sign

Answer 14

• Grasp the patella and apply a caudal glide then ask the patient to contract the quad
• Positive = retropatella pain

Question 15

Describe Clarke test (AKA Patella Grind)

Answer 15

• Add a mild compression to the patella & ask patient to contract the quad
• Positive = retropatella pain

Question 16

Foot mobility testing for hypermobility impairments in patellofemoral pain

Answer 16

• Midfoot width in NWB and WB
• > 11mm difference b/w NWB and WB
• Foot posture index score >6 (Pronated foot)

Question 17

Testing for hypo mobility impairment in patellofemoral pain

Answer 17

• Patellar tilt test for lateral patellar retinaculum
• Hamstrings Straight leg raise <79.1° (goniometry)
• Gastrocnemius Ankle DF (knee extended) <7.4° (goniometry)
• Soleus Ankle DF (knee flexed to 90°) <14.8° (goniometry)
• Quadriceps Prone knee flexion <134.0° (inclinometry)
• Iliotibial band Ober test (knee flexed to 90°) <11° (inclinometry)
• Hip IR and ER ROM testing (more with limited hip ER)

Question 18

According to the CPG for PFP which interventions are NOT recommended

Answer 18

• Dry needling
• Manual therapy for the lumbar or knee
• Modalities

Question 19

What interventions are recommended for PFP according to the CPG

Answer 19

• Taping & activity modification (Rest)
• Gait (Running)
• Movement retraining
• Strengthening
• Foot taping & orthotics
• STM to retinaculum
• Flexibility

Question 20

Describe the ACL

Answer 20

• Anteromedial Bundle: tension at full extension and max tension at 45-60º flexion
• Posterolateral Bundle: tension at full extension, <30º flexion = tension to anterior translation, & 60-90º flexion = laxity = tibial rotation

Question 21

Describe the PCL

Answer 21

• Anterolateral & Posteromedial Bundles
• 50% thicker and 2x tensile strength as ACL
• 90º flexion is most resistant to posterior force, less as knee is more extended
• Restrains IR of tibia on femur
• Posteromedial stabilizer

Question 22

Problems associated with a patella tendon reconstruction, hamstring graph reconstruction, and ACL repair

Answer 22

• Patella tendon: extension lag and quad strength deficits longer
• Hamstring graph: increased anterior knee laxity
• Repair: bridge enhanced anterior cruciate ligament repair (BEAR)

Question 23

Describe the BEAR rehab protocol

Answer 23

• Post-op locked in brace
• 2 weeks: 0º and 50º flexion
• 4 weeks: 0º to 90º
• PWB for 2 weeks and then WBAT with crutches until 4 weeks

Question 24

CPR for meniscus tear

Answer 24

• 5+ findings is 99% SP
• MOI twisting with tearing sensation
• Catching/locking
• Pain with forced hyper extension
• Pain with forced hyper flexion
• Jointline tenderness
• Pain or click with McMurray
• Discomfort or locking with Thessaly

Question 25

Symptoms/clinical findings association with articular cartilage problem

Answer 25

- Acute Trauma w Hemarthrosis - Insidious onset (gradual) - Repetitive impact aggravates - Intermittent pain & swelling - Catching or Locking - Joint-line tenderness

Question 26

Contributing factors to knee OA

Answer 26

- ACL tears that are unrepaired - Age & Loading (U-Shaped Curve): Sports, Occupations, Obesity - Joint abnormalities (chicken and egg) - Genetics - Metabolic disorders: Diabetes

Question 27

Altman criteria for diagnosis of knee OA

Answer 27

- K enlargement - No palpable warmthnee pain and 3 of 6 or more: - Age >50 - Stiffness <30min - Crepitus - Bony tenderness - Bony

Question 28

Describe the grading levels of knee OA

Answer 28

- Grade 0: no radiographic features of OA are present - Grade 1: doubtful joint space narrowing (JSN) & possible osteophytic lipping - Grade 2: definite osteophytes & possible JSN on anteroposterior WBing radiograph - Grade 3: multiple osteophytes, definite JSN, sclerosis, possible bony deformity - Grade 4: large osteophytes, marked JSN, severe sclerosis & definite bony deformity

Question 29

CPR for treatment of knee OA using hip mobilizations

Answer 29

- Hip or groin pain o paresthesia - Anterior thigh pain - Passive knee flexion less than 122º - Passive hip medial (internal) rotation less than 17º - Pain with hip distraction