Knee/Ankle joint conditions

differential diagnosis of pathologies at the knee and ankle

Patellofemoral syndrome (Runner’s knee)

- Age -20-50

- MOI- trauma, tight ITB, gmax, & TFL

- Worsen symptoms after

prolonged sitting

(Moviegoer’s sign), stairs,

kneeling

- End-range knee flexion is

painful

- Tenderness on anterior

knee especially with

patella compression

- Swelling may occur on

anterior knee

-Positive clarkes test

Patellar tendinopathy (jumper’s knee)

- Age 15-30

- Inflammation of patellar

tendon

- Onset- gradual

- MOI- gradual (repeated

eccentric overloading during

deceleration activities)

- Pain increases with

squatting and jumping

- End range knee flexion

painful

- Tenderness over patellar

tendon (inferior or

superior to patellar)

Positive Special tests:

- Patellar grind test

- Single leg hop test

- High step-up test

Prepatellar bursitis

- Age 15-50

- Inflammation of bursa due to

recurrent minor trauma of

anterior knee

- MOI- direct trauma to the

anterior aspect of the knee

- Pain increases with

kneeling

- Local swelling, fluctuation

Quadriceps muscle tear

- Age 20-40

- MOI- sudden eccentric overload

- Squatting increases

symptoms

- Bruising and/or swelling

can occur over the anterior

thigh/knee

- Knee flexion is limited

- Combined hip extension

and knee flexion is painful

- Resisted hip flexion and

knee extension is painful

- Tenderness over anterior

thigh

Osgood Schlatter disease

- Age 8-13 yrs in female, 10-15yrs in male

- Onset – sudden

- Traction apophysitis of tibial tubercle

- Visible lump over the site

- Pain with activities

(running, jumping,

squatting, kneeling, acute

knee impact, and

ascending or descending

stairs)

- Knee extension against

resistance or stressing

quads increased symptoms

- Anterior knee pain

Sinding-Larsen-Johansson syndrome

- Traction epophysitis at inferior pole of patella

- Traction epophysitis at inferior pole of patella-Pain with activities like cycling, athletics, resisted Knee extension

X-ray-fragmentation of tibial tubercle or irregular calcification

Anterior Cruciate ligament injury

- Age- 15-45

- Contact & non-contact MOI

- Contact-> Blow to the lateral

side of knee- valgus force to

knee results in ACL, MCL,

medial meniscus injury(terrible triad) or (unhappy

triad)

- Non-contact- Tibia ER on

planted foot

- Forceful hyperextension

-pain with resisted knee rotatio

- Immediate swelling of

knee and popping sound

- Feeling of instability

- Symptoms increase with

weight-bearing

- Pain at end ranges

Positive: - Lachman’s test

- Pivot Shift test

- Anterior drawer test

Medial collateral ligament injury

- Valgus forces across

medial joint line of knee

- Symptoms increases with Valgus stress (MCL)

Positive: collateral ligament instability test

Lateral collateral ligament injury

- Lateral collateral ligament- traumatic varus force across knee

- Symptoms increases with Varus stress (LCL)

Positive: collateral ligament instability test

Posterior cruciate ligament injury

- Forceful blow to anterior tibia

in knee flexed, Dashboard or

falling onto the flexed knee

- Hyperflexion

- Popping sound

- Pain in the posterior

aspect of the knee joint

which aggravates with kneeling

Positive: - Posterior Sag test

- Posterior drawer test

- Reverse Lachman test

Iliotibial band friction syndrome

- Age 25-55

- MOI- overuse

- Pain with repetitive movements, climbing or descending stairs

- Lateral knee pain diffuse & hard to localize

- Localized tenderness at lateral femoral condyle

- Ober’s test (ITB tightness)

- Noble compression test

- Renne test

Plantar fasciitis

- Age- 20-60

- MOI- gradual with no known cause

- Painful sole of foot under heel when weight bearing especially first thing in the morning

- Pronated foot or flattened arches observed

- Passive great toe extension is painful

- Plantar aspect of heel is tender on palpation

- Positive Windlass test

Achilles tendinitis

- Age 20-40

- MOI- overuse

- Jumping, and running increases symptoms on posterior ankle

- Slight swelling can be seen on posterior ankle

- Active and passive dorsiflexion is painful and limited

- Passive dorsiflexion is limited with knee in the extended position

- Resisted plantar flexion is painful

Gastrocnemius strain

- Age 20-40

- MOI- sudden overload

- Pain in the upper calf

- Heel raise increases symptoms

- Antalgic gait

- Active and passive

dorsiflexion painful and

limited with knee extended

position

- Pain on resisted plantar flexion

- Tender mid to upper calf area on palpation

Posterior tibialis tendinitis

- Age 20-40

- MOI- overuse with a flat pronated foot

- Pain on medial ankle throughout tendon

- Swelling may be present and tenderness over medial ankle

- Active and passive plantar flexion and eversion painful

- Resisted inversion with plantar flexed foot is painful

Anterior tibialis tendinitis

- Age 15-45

- MOI- overuse

- Symptoms increases with repetitive dorsiflexion on anterior lower leg

- Combined active Plantarflexion and inversion movements painful

- Passive plantar flexion painful

- Resisted dorsiflexion painful

- Tenderness over the anterolateral lower leg

Medial tibial stress syndrome (Shin splints)

- Age 15-30

- MOI- overuse

- Pain on anterior lower leg, posterior-medial lower leg

- Active combined plantarflexion and inversion painful

- Resisted plantar flexion and eversion painful

- Tenderness on posteromedial calf

Anterior Compartment syndrome

- Increased pressure in anterior compartment of leg causing an

ischemic condition of the leg

- MOI - direct trauma, muscle hypertrophy, fracture

- Severe cramping, diffuse

pain, and tightness

- Pain decreases with rest and

increases with activity

- Pain worsens with stretching

- Tender and tight

compartment on palpation

-Pain, pallor, paresis, paresthesia,

pulselessness, palpable tenderness

Acute – emergency surgery

Morton’s neuroma

- Weight-bearing increases symptoms on sole of foot

- Pronated foot or flattened arch can be observed

- Passive toe extension painful

- Tenderness with palpation on web space of toes

Tarsal tunnel syndrome

- Age 25-50

- MOI- posttraumatic, rapid weight gain, fluid retention, inflammatory, abnormal foot/ankle biomechanics or a valgus foot deformity

- Symptoms on medial malleolus, distribution of posterior tibial nerve up the leg, or down into the medial arch, plantar surface of the foot and toes

- Symptoms increases with excessive pronation in walking or running

- Pronated foot, pes planus can be observed

- Passive plantar flexion and eversion painful

- Resisted toe flexion painful

-Positive tinels sign

Metatarsal stress fracture

- Age 15-45

- MOI – overuse

- Symptoms increases with weight-bearing activities on the forefoot

- Tenderness over the fracture site

- Palpation, ultrasound, tuning fork, bone scan, MRI, CT scan

Midfoot sprain

- Age 15-40

- MOI – high impact landing, foot twisted when in fixed position

- Walking on toes increases symptoms on midfoot

- Generalized tenderness of midfoot

- pain during passive midfoot pronation and supination while the hindfoot is

stabilized.

- Weight Bearing lateral and anterior-posterior radiographs

Sever’s diseases (Calcaneal Apophysitis)

- Age 8-13 yrs

- traction apophysitis at the

insertion of Achilles tendon

- MOI- foot pronation, tight gastroc-soleus complex, jumping or landing from a height

- Limited dorsiflexion and stiffness

- Pain over the posterior-inferior heel which increases with weight-bearing

- Pain resolves with rest

- Squeeze test

- X-ray

forefoot varus

- Inversion of forefoot

- subtalar joint in neutral

forefoot valgus

- Eversion of forefoot

- subtalar joint in neutral