Week 4 Knee Physmed 2024 Asynchronous .pdf

Orthopedic Conditions & Assessment C o n d i t i o n s o f t h e Kn e e Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Apply the process of a focused regional exam of the knee using the OHPMNRS model Develop an illness script for each knee condition Develop a differential diagnosis for...

Orthopedic Conditions & Assessment C o n d i t i o n s o f t h e Kn e e Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Apply the process of a focused regional exam of the knee using the OHPMNRS model Develop an illness script for each knee condition Develop a differential diagnosis for common knee conditions and presentations Demonstrate selected orthopaedic assessments accurately and diagnostically Demonstrate basic but effective in-office treatments for common knee conditions and presentations Conditions of the Knee ACL & PCL Sprains IT-Band Syndrome MCL & LCL Sprain Terrible Triad Patellar Dislocation Chondromalacia Patellae Osgood Schalters Medial Tibial Stress Syndrome (MTSS) or Shin Splints Special Orthopaedic Tests for the Knee Collateral Ligament Stability Test (MCL & LCL) Anterior Drawer Test Posterior Drawer Test Lachman Test McMurray’s Test Apley’s Distraction Test Apley’s Compression Test Ober’s Test (Modified) Ober’s Test (Original) Apprehension Test Bounce Home Test Clarks Patellar Grind Test Disco/Thessaly ACL Sprain or Tear Definition: Partial or complete tearing of the anterior cruciate ligament (ACL) of the knee ACL: limits anterior translation of the tibia in relation to the distal femur Differential Diagnosis: Fracture (severe bruising or swelling, cannot weight bear) Patellar or knee dislocation Meniscus or collateral ligament tear PCL sprain or tear Osteoarthritis of the knee ACL Sprain or Tear History: Mechanism of injury: Running with an abrupt change in direction or landing from a jump or hyper-extension of the knee Deep knee pain following trauma Potential audible ‘pop’ or ‘snap’ at the time of injury Knee swelling in <2 hours Often associated with the “terrible triad” or “unhappy triad ACL, MCL and medial meniscus tear ACL Sprain or Tear Physical: Inspection: Joint deformity or bony abnormality Palpation: Joint line (meniscus) and collateral ligaments for tenderness Motion: AROM & PROM: limited in extension due to pain RROM: WNL or weak due to pain Neurovascular: Unremarkable ACL Sprain or Tear Special Tests: ANTERIOR DRAWER (+) Pain -> Anterior cruciate ligament strain (+) Excessive motion -> Anterior cruciate ligament rupture https://www.clinicaladvisor.com/slideshow/slides/tests-to-assess-acl-rupture/ ACL Sprain or Tear Special Tests: LACHMANS TEST (ANTERIOR) (+) Pain with anterior translation -> ACL Sprain (+) Excessive motion -> ACL rupture https://www.clinicaladvisor.com/slideshow/slides/tests-to-assess-acl-rupture/ PCL Sprain or Tear Definition: Partial or complete rupture of the posterior cruciate ligament (PCL) of the knee PCL: limits posterior translation of the tibia in relation to the distal femur Differential Diagnosis: Fracture (severe bruising or swelling, cannot weight bear) Patellar or knee dislocation Meniscus or collateral ligament tear ACL sprain or tear Osteoarthritis of the knee PCL Sprain or Tear History: Mechanism of injury: Fall on a flexed knee (A->P force on proximal tibia) or hyperflexion or hyperextension injury Pain : deep knee pain after injury Potential audible ‘pop’ or ‘snap’ at the time of injury Knee swelling in <2 hours Sensation of instability or apprehension Following injury most are able to walk and may not know they are injured PCL Sprain or Tear Physical: Inspection: Joint deformity or bony abnormality Posterior sag sign– tibia drops posteriorly when supine with knees bent Palpation: Joint line (meniscus) and collateral ligaments for tenderness https://www.google.com/search?q=posterior+drawer+test+if+the+knee&tbm=isch&ved=2ahUKEwjzpt3owM_8AhVHITQIHdvPAXYQ2cCegQIABAA&oq=posterior+drawer+test+if+the+knee&gs_lcp=CgNpbWcQA1AAWOEJYOsKaABwAHgAgAFYiAGkBZIBAjEwmAEAoAEBqgELZ3dzLX dpei1pbWfAAQE&sclient=img&ei=dQ3HY7OYA8fC0PEP25-HsAc&bih=696&biw=1440&rlz=1C5CHFA_enCA940CA942#imgrc=EY7RbVoBa_nwGM PCL Sprain or Tear Physical: Motion: AROM & PROM: limited due to pain RROM: WNL or weak due to pain Neurovascular: Unremarkable PCL Sprain or Tear Special Tests: POSTERIOR DRAWER (+) Pain -> PCL strain (+) Excessive motion -> PCL rupture https://www.physiotutors.com/wiki/valgus-stress-test/ PCL Sprain or Tear Special Tests: LACHMANS TEST (POSTERIOR) (+) Pain with posterior translation -> PCL Sprain (+) Excessive motion -> PCL rupture = Posterior = Anterior https://www.clinicaladvisor.com/slideshow/slides/tests-to-assess-acl-rupture/ MCL Sprain or Tear Definition: Partial or complete tearing of the medial (tibial) collateral ligament (MCL) of the knee Differential Diagnosis: Medical meniscus or ACL damage Patellar subluxation or dislocation Avulsion or tibial plateau fracture MCL Sprain or Tear History: Acute medial knee pain usually following a single traumatic event Valgus force: lateral to medial force Audible ‘pop’ or tearing sensation at time of injury Knee swelling? Knee will feel weak or unstable MCL Sprain or Tear Physical: Inspection: Possible swelling or bruising Palpation: Point tenderness over MCL Joint line (meniscus) Motion: AROM & PROM: limited due to pain RROM: WNL Neurovascular: Unremarkable MCL Sprain or Tear Special Tests: VALGUS STRESS TEST (+) Pain – MCL Sprain (+) Increased motion or gapping – MCL Rupture Force = L -> M https://www.physiotutors.com/wiki/valgus-stress-test/ LCL Sprain or Tear Definition: Partial or complete tearing of the lateral (fibular) collateral ligament (LCL) of the knee Differential Diagnosis: ITB Syndrome Meniscus Tear Biceps Femoris Tendinopathy Tibial plateau or Fibular Head Fracture ACL Sprain/Tear LCL Sprain or Tear History: Acute lateral knee pain usually following a single traumatic event Varus force: medial to lateral force Audible ‘pop’ or tearing sensation at time of injury Knee swelling? Knee will feel weak or unstable LCL Sprain or Tear Physical: Inspection: Possible swelling or bruising Palpation: Point tenderness over LCL (figure 4 position) Motion: AROM & PROM: lateral knee pain with full extension RROM: WNL or limited due to pain Neurovascular: Unremarkable Rule out common peroneal nerve pathology – runs in this area LCL Sprain or Tear Special Tests: VARUS STRESS TEST (+) Pain – LCL strain (+) Increased motion/gapping – LCL Rupture Force = M -> L https://www.physiotutors.com/wiki/varus-stress-test/ Meniscus Tear Definition: Tear or derangement of the fibrocartilaginous discs between the tibial & femoral condyles within the knee joint Differential Diagnosis: Knee DJD or Osteoarthritis Osteochondritis Dissecans ACL, PCL, MCL or LCL injury Patellofemoral syndrome ITB Syndrome Terrible Triad*** Meniscus Tear History: Mechanism of Injury: Repetitive activities of the knee, planting and twisting motions or secondary to osteoarthritis Joint line pain Possible joint locking, catching, clicking, crepitus or sensation of giving way (instability) Swelling usually occurs as a delayed symptom Major Types of Meniscal Tears https://www.uptodate.com/contents/meniscal-injury-of-the-knee Meniscus Tear Physical: Inspection: Possible swelling or redness ~50% of cases Palpation: Joint line tenderness** Motion: AROM & PROM: Pain at end range Mechanical block to motion or locking can occur with displaced tears RROM: WNL or limited due to pain Neurovascular: Unremarkable Meniscus Tear Special Tests: APLEYS COMPRESSION TEST (+) Pain or crepitus with compression and rotation -> meniscal lesion APLEYS DISTRACTION TEST (+) DECREASED pain or crepitus with knee distraction https://www.orthobullets.com/recon/12755/knee-physical-exam--adult Meniscus Tear Special Tests: MCMURRAYS TEST (+) Pain or crepitus -> meniscal lesion Valgus force with external rotation -> lateral meniscus Varus force with internal rotation-> medial meniscus https://standardofcare.com/mcmurray-test/ Terrible or Unhappy Triad Commonly affected together: Medial Meniscus ACL MCL Iliotibial Band Syndrome Definition: Inflammation & irritation of the distal portion of the iliotibial tendon as it rubs against the lateral femoral condyle Differential Diagnosis: Biceps femoris tendinopathy LCL sprain Lateral meniscal injury Chondromalacia patella Trochanteric bursitis often coexists Iliotibial Band Syndrome History: Pain: diffuse, lateral knee pain that starts after activity, can also have pain over the greater trochanter Worse: Continued activity Running up hill or up/down stairs There may be an audible repetitive popping noise in the knee when walking or running Iliotibial Band Syndrome Physical: Inspection: Unremarkable or possible swelling/edema at distal ITB Palpation: Tenderness ~2cm above lateral joint line Tenderness over greater trochanter TFL/glute max hypertonicity or MFTP Iliotibial Band Syndrome Physical: Motion: AROM & PROM: Pain with knee flexion/extension Hip adduction (tenses ITB) RROM: May show decreased strength of knee extensors, flexors and hip abductors Neurovascular: Unremarkable Iliotibial Band Syndrome Special Tests: OBERS (Modified) (+) Hip Pain -> Hip joint pathology (+) Trochanteric Pain -> Trochanteric bursitis (+) Decreased ROM – ITB contracture https://www.youtube.com/watch?v=68ouuhDyVNI Patellar Dislocation Definition: Loss of normal articulation between the patella & patellar groove of the distal femur. Dislocation is usually lateral, can lead to chronic subluxation or recurrent dislocations Differential Diagnosis: ACL, MCL, LCL sprain Fracture of patella or subchondral fracture Meniscal tear Chondromalacia patellae Patellar Dislocation History: Knee pain (may look very similar to moderate to severe knee sprain) History of direct or indirect trauma to knee (physical blow or twisting while the foot is planted) Possible grinding or tearing sensation during injury May have heard a pop with dislocation and a second pop with spontaneous relocation Patient often expresses apprehension about knee movement or during activities Patellar Dislocation History: Knee pain (may look very similar to moderate to severe knee sprain) History of direct or indirect trauma to knee (physical blow or twisting while the foot is planted) Possible grinding or tearing sensation during injury May have heard a pop with dislocation and a second pop with spontaneous relocation Patient often expresses apprehension about knee movement or during activities Patellar Dislocation Physical: Inspection: Possible swelling or bruising over vastus medialis Knee will often be flexed (30-45*) Can often visualize the lateral displacement Palpation: Patella will not be in the normal location (can compare with the other knee) Myospasm or trigger points in vastus muscles Patellar Dislocation Physical: Motion: limited & painful, but possible AROM: will show abnormal tracking (J-sign) PROM: painful, possibly limited at end range RROM: WNL or limited due to pain Neurovascular: Should be conducted but often unremarkable Patellar Dislocation Patellar Dislocation Special Tests: PATELLAR APPREHENSION TEST Chondromalacia Patella Definition: Premature degeneration of the patellar cartilage During the movement from flexion to extension, different parts of the patella articulate with the femoral condyles The odd facet does not come into contact with the femoral condyles until at least 135 Degrees of flexion is reached. Incorrect alignment or mal-alignment of the patellar movement over the femoral condyles can lead to patelofemoral arthralgia Differential Diagnosis: ACL, MCL, LCL sprain Fracture of patella or subchondral fracture Meniscal tear Patellofemoral Syndrome Chondromalacia Patella History: Knee pain History of direct or indirect trauma to knee or NO trauma Possible grinding or tearing sensation during walking up or down stairs A general pain Chondromalacia Patella Physical: Inspection: No to minimal swelling over knee area due to wear and tear Patella might be laterally displaced during walking Palpation: Patella will not be in the normal location (can compare with the other knee) Myospasm or trigger points in vastus muscles Chondromalacia Patella Physical: Motion: NOT limited & NOT painful (No nerves in cartilage), but possible AROM: will show abnormal tracking (Lateral) PROM: painful, possibly limited at end range RROM: WNL Neurovascular: Should be conducted but often unremarkable Chondromalacia Patella Special Tests: Clarks Patellar Grind Test (+) Grinding sensation or pain https://www.youtube.com/watch?v=68ouuhDyVNI Patellofemoral Syndrome Definition: Patellofemoral pain syndrome occurs when nerves sense pain in the soft tissues and bone around the kneecap. These soft tissues include the tendons, the fat pad beneath the patella, and the synovial tissue that lines the knee joint. In some cases of patellofemoral pain, a condition called chondromalacia patella is present. Chondromalacia patella is the softening and breakdown of the articular cartilage on the underside of the kneecap. There are no nerves in articular cartilage—so damage to the cartilage itself cannot directly cause pain. It can, however, lead to inflammation of the synovium and pain in the underlying bone. Differential Diagnosis: ACL, MCL, LCL sprain Fracture of patella or subchondral fracture Meniscal tear Patellofemoral Syndrome Causes Overuse In many cases, PFPS is caused by vigorous physical activities that put repeated stress on the knee —such as jogging, squatting, and climbing stairs. It can also be caused by a sudden change in physical activity. This change can be in the frequency of activity—such as increasing the number of days you exercise each week. It can also be in the duration or intensity of activity— such as running longer distances. Use of improper sports training techniques or equipment Changes in footwear or playing surface Patellar Malalignment Patellofemoral pain syndrome can also be caused by abnormal tracking of the kneecap in the trochlear groove. In this condition, the patella is pushed out to one side of the groove when the knee is bent. This abnormality may cause increased pressure between the back of the patella and the trochlea, irritating soft tissues. Causes Factors that contribute to poor tracking of the kneecap include: Problems with the alignment of the legs between the hips and the ankles. Problems in alignment may result in a kneecap that shifts too far toward the outside or inside of the leg, or one that rides too high in the trochlear groove—a condition called patella alta. Muscular imbalances or weaknesses, especially in the quadriceps muscles at the front of the thigh. When the knee bends and straightens, the quadriceps muscles and quadriceps tendon help to keep the kneecap within the trochlear groove. Weak or imbalanced quadriceps can cause poor tracking of the kneecap within the groove. Patellofemoral Syndrome The most common symptom of PFPS is a dull, aching pain in the front of the knee. This pain—which usually begins gradually and is frequently activityrelated—may be present in one or both knees. Other common symptoms include: Pain during exercise and activities that repeatedly bend the knee, such as climbing stairs, running, jumping, or squatting. Pain on the front of the knee after sitting for a long period of time with your knees bent, such as one does in a movie theater or when riding on an airplane. Pain related to a change in activity level or intensity, playing surface, or equipment. Popping or crackling sounds in your knee when climbing stairs or when standing up after prolonged sitting. Patellofemoral Syndrome Special Tests: No specific test Depending on the degrees of damage, multiple tests may be positive due to inflammation. Clark’s Apprehension Test Bounce Home Test OR NO TESTS ARE POSITIVE https://www.youtube.com/watch?v=68ouuhDyVNI Osgood-Schlatter Disease/ Syndrome Definition: A condition that primarily affects adolescents, particularly those who are going through a growth spurt. It is characterized by inflammation of the patellar ligament, which connects the kneecap (patella) to the shinbone (tibia). This inflammation leads to pain and swelling in the area just below the kneecap. Causes Age and Gender: Osgood-Schlatter disease typically occurs in adolescents between the ages of 10 and 15, during periods of rapid growth. It is more common in boys than in girls. Physical Activity: The condition is often associated with activities that involve running, jumping, and rapid changes in direction, such as those seen in sports like soccer, basketball, and gymnastics. Symptoms The main symptom is pain and swelling just below the kneecap. The pain may worsen during activities that involve bending or straightening the knee, such as running or climbing stairs. The affected area may also be tender to touch. Bony Bump: In some cases, a bony bump or prominence may develop at the site of the inflammation. This is an overgrowth of bone caused by the constant pulling of the patellar ligament on the developing bone. FYI The exact cause of Osgood-Schlatter disease is not fully understood, but it is believed to be related to the stress placed on the growing bones and the developing patellar ligament during periods of rapid growth. The repeated stress and strain can lead to inflammation at the site where the patellar ligament attaches to the shinbone. Osgood-Schlatter Disease Special Tests: No specific test Just signs and symptoms https://www.youtube.com/watch?v=68ouuhDyVNI Medial Tibial Stress Syndrome (MTSS) or Shin Splints Definition: A common condition characterized by pain along the inner edge of the shinbone (tibia). This condition often occurs in individuals who engage in repetitive, high-impact activities, particularly those involving running or jumping. Shin splints are not a specific medical diagnosis but rather a term used to describe a variety of lower leg pain symptoms. Causes The exact cause of shin splints is not always clear, but it is believed to result from overuse or repetitive stress on the shinbone and the tissues attaching the shinbone to the muscles. Factors such as flat feet, improper footwear, and training errors (such as overtraining or sudden increases in intensity) may contribute to the development of shin splints. Symptoms Pain is the primary symptom along the inner edge of the shinbone, typically between the knee and ankle. The pain may be diffuse or concentrated in a specific area and is often described as a dull, aching discomfort. Shin splints are commonly associated with activities that involve running, jumping, or other high-impact exercises. They often occur in athletes or individuals who suddenly increase the intensity, duration, or frequency of their workouts. Medial Tibial Stress Syndrome (MTSS) or Shin Splints Special Tests: No specific test Just signs and symptoms Imaging https://www.youtube.com/watch?v=68ouuhDyVNI