MUSCULOSKELETAL EXAMINATON OF THE KNEE (P1: No special tests)

If the knee experiences a valgus force (with or without rotation or twisting), it can lead to an injury in which collateral ligament?

Medial collateral ligament

True or False:

Valgus force leading to injury to the medial collateral ligament is frequently accompanied by injury to the anteromedial capsule, medial meniscus, and anterior cruciate (“terrible triad”).

False:

Valgus force leading to injury to the medial collateral ligament is frequently accompanied by injury to the posteromedial capsule, medial meniscus, and anterior cruciate (“terrible triad”).

True or False:

Hyperextension as the MOI can lead to anterior cruciate injuries, often associated with meniscus tears.

True

flexion with posterior translation as the MOI often involves the ______________________

Posterior cruciate ligament

True or False:

Varus force leads to injury of the lateral collateral ligament posteromedial capsule, and the posterior cruciate ligament.

False:

Varus force leads to injury of the lateral collateral ligament posterolateral capsule, and the posterior cruciate ligament.

Tibiofemoral Joint :

Resting position:

Close packed position:

Capsular pattern:

Tibiofemoral Joint :

Resting position: 25° flexion

Close packed position: Full extension, lateral rotation of tibia

Capsular pattern: Flexion, extension

True or False:

meniscal injuries, especially those on the lateral side, occur as a result of a torsion injury that combines compression and rotation.

False:

meniscal injuries, especially those on the medial side, occur as a result of a torsion injury that combines compression and rotation.

Slowly developing forces tend to cause bony __________

Rapidly developing forces tend to tear ____________

Avulsions

Ligaments

True or False

If one or more ligaments have been torn, the knee may have been dislocated which, if it has occurred, may lead to a vascular injury.

False:

If two or more ligaments have been torn, the knee may have been dislocated which, if it has occurred, may lead to a vascular injury.

The possibility of vascular affectation during knee dislocation prompts the examination of which pulses?

popliteal and dorsalis pedis pulse.

In young children, injuries to the ________ or _______ may occur instead of injury to the ligaments

In young children, injuries to the growth plate or physis may occur instead of injury to the ligaments

especially during a rapid growth spurt when the physis is weaker than the ligaments

Growth plate injuries may occur to the:

• distal femoral physis

• proximal tibial physis

• tibial tubercle apophysis (traction epiphysis)

Injury to the tibial tubercle apophysis is also called what?

Osgood-Schlatter disease

True or False:

There is less chance of injury when the lower limb is a closed kinetic chain.

False:

There is less chance of injury when the lower limb is an open kinetic chain.

The hamstrings are often injured near the end of which phase?

Swing phase

Just before heel strike

True or False:

hamstring injuries may occur following insidious onset of progressive hamstring tightness.

True

This condition has a more insidious onset with swelling, unexplained deep pain, and a palpable mass as the first signs often combined with night pain, constant ache, and difficulty using the limb (i.e., limp)—all of which get progressively worse.

Bone Tumors

Structures Possibly Injured during:

Varus or valgus contact without rotation

• Collateral ligament

• Epiphyseal fracture

• Patellar dislocation or subluxation

Structures Possibly Injured during:

Varus or valgus contact with rotation

• Collateral and cruciate ligaments

• Collateral ligaments and patellar dislocation or subluxation

• Meniscus tear

Structures Possibly Injured during:

Blow to patellofemoral joint, or fall on flexed knee, foot dorsiflexed

• Patellar articular injury or osteochondral fracture

Structures Possibly Injured during:

Blow to tibial tubercle, or fall on flexed knee, foot plantar flexed

• Posterior cruciate ligament

Structures Possibly Injured during:

Anterior blow to tibia, resulting in knee hyperextension (contact hypertension)

• Anterior cruciate ligament

• Anterior and posterior cruciate ligament

Structures Possibly Injured during:

Noncontact hyperextension

• Anterior cruciate ligament

• Posterior capsule

Structures Possibly Injured during:

Noncontact deceleration

• Anterior cruciate ligament

Structures Possibly Injured during:

Noncontact deceleration, with tibial medial rotation or femoral lateral rotation on fixed tibia

• Anterior cruciate ligament

Structures Possibly Injured during:

Noncontact, quickly turning one way with tibia rotated in opposite direction

• Patellar dislocation or subluxation

Structures Possibly Injured during:

Noncontact, rotation with varus or valgus loading

• Meniscus injury

• Medial collateral ligament

Structures Possibly Injured during:

Noncontact, compressive rotation

• Meniscus injury

• Osteochondral fracture

Structures Possibly Injured during:

Hyperflexion

• Meniscus (posterior horn)

• Anterior cruciate ligament

Structures Possibly Injured during:

Forced medial rotation

• Meniscus injury (lateral meniscus)

Structures Possibly Injured during:

Forced lateral rotation

• Meniscus injury (medial meniscus)

• Medial collateral ligament and possibly anterior cruciate ligament

• Patellar dislocation

Structures Possibly Injured during:

Flexion-varus-medial rotation

• Anterolateral instability

Structures Possibly Injured during:

Flexion-valgus-lateral rotation

• Anteromedial instability

Structures Possibly Injured during:

Dashboard injury

• Isolated posterior cruciate ligament

• Posterior cruciate ligament and posterior capsule

• Posterolateral instability

• Posteromedial instability

• Patellar fracture

• Tibial fracture (proximal)

• Tibial plateau fracture

• Acetabular and pelvic fracture

True or False:

Artificial playing surfaces increase the risk of posterior cruciate ligament injuries.

False:

Artificial playing surfaces increase the risk of anterior cruciate ligament injuries.

True or False:

Altered neuromuscular activation patterns that may increase the risk of injury especially when the individual is fatigued which can ultimately lead to arthritic changes.

True

True or False:

A distinct pop may indicate a posterior cruciate ligament or medial collateral ligament tear or osteochondral fracture

False:

A distinct pop may indicate an anterior cruciate ligament or medial collateral ligament tear or osteochondral fracture

Popping on the lateral aspect of the knee may be due to the __________ tendon snapping over the __________________ within ________ of the muscle’s attachment into the femur

Popping on the lateral aspect of the knee may be due to the popliteus tendon snapping over the lateral femoral inferoposterior tubercle within 2 cm of the muscle’s attachment into the femur

True or False:

Posterior cruciate ligament injuries typically have more vague symptoms of unsteadiness or discomfort

True

True or False:

Patients with an chronic posterior cruciate ligament injury have moderate effusion, posterior knee pain, or pain with kneeling.

False:

Patients with an acute posterior cruciate ligament injury have moderate effusion, posterior knee pain, or pain with kneeling.

True or False:

Acceleration and twisting and cutting injuries may involve the cruciate ligaments.

False:

Acceleration and twisting and cutting injuries may involve the meniscus and ligaments.

True or False:

Deceleration injuries often involve the cruciate ligaments

True

Constant speed with cutting may involve the _______ cruciate ligament.

Constant speed with cutting may involve the anterior cruciate ligament.

True or False:

Aching pain may indicate mechanical changes, whereas sharp, “catching” pain usually indicates a degenerative problem.

False:

Aching pain may indicate degenerative changes, whereas sharp, “catching” pain usually indicates a mechanical problem.

True or False:

Arthritic pain is more likely to be associated with stiffness in the morning and worsens with activity.

False:

Arthritic pain is more likely to be associated with stiffness in the morning and eases with activity.

True or False:

Anterior knee pain may be due to patellofemoral problems, bursa (prepatellar, infrapatellar) pathology, fat pad pathology, tendinosis, or Osgood-Schlatter disease.

True

True or False:

Patellofemoral pain tends to be sudden and occurs spontaneously, often from trauma.

False:

Patellofemoral pain tends to be insidious and occurs spontaneously, often from overuse.

True or False:

Pain at rest is not usually mechanical in origin.

True

True or False:

Pain during activity is usually seen in structural abnormalities, such as subluxation or patellar tracking disorders.

True

True or False:

Pain after activity or with overuse is characteristic of degenerative disorders, such as synovial plica irritation or early tendinosis or paratenonitis leading to jumper’s knee or Sinding-Larsen-Johansson syndrome.

False:

Pain after activity or with overuse is characteristic of inflammatory disorders, such as synovial plica irritation or early tendinosis or paratenonitis leading to jumper’s knee or Sinding-Larsen-Johansson syndrome

Generalized pain in the area of the knee is usually characteristic of __________ or __________ of muscles or ligaments.

Generalized pain in the area of the knee is usually characteristic of contusions or partial tears of muscles or ligaments.

True or False:

Pain rather than instability tends to be the major presenting factor in complex ligament disruptions or muscle dysfunction (e.g., quadriceps rupture).

False:

Instability rather than pain tends to be the major presenting factor in complex ligament disruptions or muscle dysfunction (e.g., quadriceps rupture).

Pain in the knee on ankle movements may implicate the _____________ joint

Pain in the knee on ankle movements may implicate the superior tibiofibular joint

True or False:

Constant pain that is unrelated to activity, time, or posture, because it usually indicates serious pathology, such as a tumor

True

The knee giving way usually indicates:

• instability in the knee

• meniscus pathology

• patellar subluxation (if present when rotation or stopping is involved)

• undisplaced osteochondritis dissecans (OCD),

• patellofemoral syndrome

• plica

• loose body

True or False:

Giving way when walking uphill or downhill is more likely the result of a retropatellar lesion.

True

If the patient complains that the patella “slips out of place,” it may be because of ______________ or a _____________

If the patient complains that the patella “slips out of place,” it may be because of a patellar subluxation or a pathological plica

True or False:

True locking of the knee is common. Loose bodies may cause recurrent locking.

False:

True locking of the knee is rare. Loose bodies may cause recurrent locking.

Locking in the knee usually means that the knee cannot fully _________ with _______ often being normal, and it is related to _________ pathology

Locking in the knee usually means that the knee cannot fully extend with flexion often being normal, and it is related to meniscus pathology

Hamstring muscle spasm may also limit extension and is sometimes referred to as ____________.

Hamstring muscle spasm may also limit extension and is sometimes referred to as spasm locking.

This is momentary locking or giving way as a result of reflex inhibition or pain.

Catching

____________ may be caused by degeneration or by one structure’s snapping over another.

Grating or clicking may be caused by degeneration or by one structure’s snapping over another.

True or False:

Swelling with no activity may be caused by instability, and tightness at rest may be caused by arthritic changes or patellofemoral dysfunction.

False:

Swelling with activity may be caused by instability, and tightness at rest may be caused by arthritic changes or patellofemoral dysfunction.

True or False:

Swelling with pivoting or twisting may be a result of cruciate ligament problems or instability at the tibiofemoral joint.

False:

Swelling with pivoting or twisting may be a result of meniscus problems or instability at the tibiofemoral joint.

True or False:

Recurrent swelling caused by climbing or descending slopes or stairs may be related to patellofemoral dysfunction.

True

True or False:

Often there is no swelling in the knee after severe injury

True

True or False:

Synovial swelling may occur 1 to 2 hours after the injury.

False:

Synovial swelling may occur 8 to 24 hours after the injury

True or False:

Swelling caused by blood begins to occur almost immediately.

True

True or False:

80% of the time if there is immediate swelling after trauma, the problems is extracapsular.

False:

80% of the time if there is immediate swelling after trauma, the problems is intracapsular.

Localized swelling may be caused by an inflamed _______

Localized swelling may be caused by an inflamed bursa

The ____________________ bursa has been noted as a source of anterior knee pain and could be misdiagnosed as patellofemoral arthralgia or Osgood-Schlatter disease.

The deep infrapatellar bursa has been noted as a source of anterior knee pain and could be misdiagnosed as patellofemoral arthralgia or Osgood-Schlatter disease.

If the onset of pain is anterior and insidious what condition can be expected?

patellofemoral pain syndrome

If the onset of pain is posterior or lateral and insidious what condition can be expected?

Tendinopathies

In the neutrally aligned knee, the medial compartment bears how much percent of the load across the knee?

60% to 70%

True or False:

Although in adults the legs should be relatively straight, in the child, the normal development of the knee is from genu valgum to straight, to genu varum, and then to straight.

False:

Although in adults the legs should be relatively straight, in the child, the normal development of the knee is from genu varum to straight, to genu valgum, and then to straight.

Initially, a child’s lower limbs are in genu varum until __________months, when they straighten

Initially, a child’s lower limbs are in genu varum until 18 or 19 months, when they straighten

The knee then goes into genu valgum until approximately ___________ years of age

The knee then goes into genu valgum until approximately 3 to 4 years of age

The limbs should be almost straight by age ____ years and should remain that way.

The limbs should be almost straight by age 6 years and should remain that way.

In the adult, the knee is normally in approximately how many degrees of valgus.

6° of valgus

True or False:

When checking for genu valgum, a distance of 9 to 10 cm (3.5 to 4 inches) between the ankles is considered excessive.

True

True or False:

If two or more fingers (4 cm [1.6 inches]) fit between the knees when the ankles are together, the patient has a valgus deformity or genu valgum.

False:

If two or more fingers (4 cm [1.6 inches]) fit between the knees when the ankles are together, the patient has a varus deformity or genu varum.

True or False:

On x-ray studies, the normal tibiofemoral shaft angle is approximately 9°

False:

On x-ray studies, the normal tibiofemoral shaft angle is approximately 6°

Miserable malalignment syndrome:

• (posterior/anterior?) pelvic tilt

• (decreased/increased?) hip/femoral anteversion

• tibial ________

• (increased/decreased?) tibiofemoral angle

• genu __________

• navicular ______

• increased foot ________

Miserable malalignment syndrome:

• anterior pelvic tilt

• increased hip/femoral anteversion

• tibial torsion

• decreased tibiofemoral angle

• genu recurvatum

• navicular drop

• increased foot pronation

True or False:

excessive hip abduction and lateral rotation along with relative medial deviation of the knee and tibial abduction can result in static knee valgus.

False:

excessive hip adduction and medial rotation along with relative medial deviation of the knee and tibial abduction can result in dynamic knee valgus

result of medial collapse during loading

Dynamic Knee Valgus is also accompanied by:

• __________ rotation of the tibia

• ___________ translation of the knee

• rear foot ________ or navicular drop

• (increased/decreased?) dorsiflexion.

Dynamic Knee Valgus is also accompanied by:

• lateral rotation of the tibia

• anterior translation of the knee

• rear foot eversion or navicular drop

• decreased dorsiflexion.

True or False:

Normally, a person does not stand with the knees fully extended. If, however, the patient has an reduced lordosis, the knees are often hyperextended to maintain the center of gravity.

False:

Normally, a person does not stand with the knees fully extended. If, however, the patient has an excessive lordosis, the knees are often hyperextended to maintain the center of gravity.

True or False:

Hyperextended knee can lead to anterior knee pain

False:

Hyperextended knee can lead to posterior knee pain

True or False:

If there is extracapsular swelling, or at least sufficient swelling the knee assumes the resting position.

False:

If there is intracapsular swelling, or at least sufficient swelling the knee assumes the resting position.

____________ swelling is evident over the entire joint
_____________ swelling tends to be more localized

Intracapsular swelling is evident over the entire joint
extracapsular swelling tends to be more localized

True or False

Second-degree quad strains may be indicated by muscle “bunching,” abnormal mechanics , a palpable defect, and the knee not extending fully.

False:

Third-degree quad strains may be indicated by muscle “bunching,” abnormal mechanics , a palpable defect, and the knee not extending fully.

True or False

During 3rd degree strains, the knee only stable in full extension when standing as the position is held by the iliotibial band.

True

• Patella tilting outward is called?

• Patella tilting inward is called?

• “grasshopper eyes” patellae

• “squinting” patellae

True or False:

If patellar deviations are seen in the observation phase, they are considered dynamic problems

False:

If patellar deviations are seen in the observation phase, they are considered static problems

the examiner should test patellar movement passively and watch the patellae during active movements to see whether it is a dynamic problem as well.

A squinting or rotated patella may indicate ________ femoral or ________ tibial torsion

Medial Femoral

Lateral Tibial

Patients with abnormal torsion are prone to patellofemoral instability

• hyperextended knee is called?

• Patient prefers flexed knee position during PA, this deformity is called?

• one or both patellae are higher, this is called?

• one or both patellae are lower, this is called?

• Genu recurvatum

• Fixed flexion deformity

• Patella Alta

• Patella Baja or Infra

True or False:

patella alta can increase the patellofemoral contact force during extension, which may contribute to anterior knee pain.

False:

patella alta can increase the patellofemoral contact force during flexion, which may contribute to anterior knee pain.

This sign may be present with an abnormally high patella and a prominent the infrapatellar fat pad or an inflamed infrapatellar bursa.

Camel sign

This finding is especially noticeable in females

True or false:

If the superior pole of the patella tilts in, fat pad irritation may occur. Habitual genu recurvatum may make a patient prone to anterior cruciate tears.

FALSE:

If the inferior pole of the patella tilts in, fat pad irritation may occur. Habitual genu recurvatum may make a patient prone to posterior cruciate tears.

If one knee (normal) hyperextends and the other one (injured) does not, it may indicate ____________ pathology that is limiting extension.

If one knee (normal) hyperextends and the other one (injured) does not, it may indicate meniscus pathology that is limiting extension.

Swelling of posterior bursa of the knee is also called?

Popliteal / Baker’s cyst