DOCSLIB.ORG

Assessment and Management of Knee Pain

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Assessment and Management of Knee Pain Topics in PAIN MANAGEMENT Vol. 34, No. 7 Current Concepts and Treatment Strategies February 2019 CONTINUING EDUCATION ACTIVITY Assessment and Management of Knee Pain Angela Starkweather, PhD, ACNP-BC, FAAN The purpose of this article is to review evidence about the assessment and management of knee pain. Learning Objectives/Outcomes: After participating in this CME/CNE activity, the provider should be better able to: 1. Describe 3 of the most common causes of knee pain in adult patients. 2. Explain the various physical examination maneuvers that can be performed to detect mechanical knee injuries. 3. Compare treatment approaches for the common causes of knee pain, including active and passive therapies. Key Words: Knee pain, Meniscal injuries, Osteoarthritis, Patellofemoral pain syndrome nee pain is one of the top 10 most common reasons for adjustments for age and body mass index.2 Athletes with pre- K outpatient visits.1 Data from the National Health and vious knee injuries are at significantly higher risk of suffering Nutrition Examination Survey and Framingham Osteoarthritis from chronic knee pain than the general population.3 Overall, Study found that knee pain and symptomatic knee osteoarthri- people with knee pain report worse physical functioning and tis have risen 10% to 25% over the past several decades, after quality of life, compared with those without knee pain, which emphasizes the need for effective management of pain in affected individuals.4 Because knee pain can be caused by a Inside This Issue wide range of bone or soft tissue injuries, infections, or chronic Assessment and Management of Knee Pain . 1 diseases (gout, osteoarthritis), identifying the most efficient Walking the Line: FDA Warns Against Any Off-Label Dr. Starkweather is Professor and Director, Center for Advancement in Managing Pain, University of Connecticut School of Nursing, 231 or Compounded Drugs for Intrathecal Pumps . 8 Glenbrook Rd, Storrs, CT 06269; E-mail: angela.starkweather@ ICYMI: In Case You Missed It . 9 uconn.edu. The author, faculty, and staff in a position to control the content of this CE Quiz . 11 CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity. CME Accreditation Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on January 31, 2021. CNE Accreditation Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Lippincott Professional Development will award 1.0 contact hours for this continuing nursing education activity. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on December 4, 2020. 1 TTPMv34n7.inddPMv34n7.indd 1 008/01/198/01/19 77:39:39 PPMM Topics in Pain Management February 2019 CO-EDITORS process for diagnosis and treatment is a priority for clinicians across different settings. Elizabeth A.M. Frost, MD Professor of Anesthesiology Icahn School of Medicine at Mount Sinai New York, NY Knee pain and symptomatic knee osteoarthritis have risen 10% to 25% Angela Starkweather, PhD, ACNP-BC, CNRN, FAAN Professor of Nursing over the past several decades. University of Connecticut School of Nursing Storrs, CT Initial Assessment of Knee Pain ASSOCIATE EDITOR With presentation of acute knee pain, initial assessment should focus on history-taking with determination of mecha- Anne Haddad nism of injury, precise location and characteristics of symp- Baltimore, MD toms, and function.5 The clinician should elicit the patient’s description of the pain and its characteristics, such as timing (acute or insidious), EDITORIAL BOARD location, duration, intensity, quality, radiation, and alleviating Jennifer Bolen, JD or aggravating factors. The clinician should also ask about The Legal Side of Pain, Knoxville, TN other symptoms that may not seem to be related, and which either precede or accompany the presence of knee pain. These C. Alan Lyles, ScD, MPH, RPh symptoms might include fever, chills, pharyngitis or sore University of Baltimore, Baltimore, MD throat, or skin rash. Examination of the knee includes observa- tion and palpation for joint tenderness, range of motion, weight-bearing ability, and specific tests to identify joint insta- Stephen Silberstein, MD 6 Jefferson Headache Center, Philadelphia, PA bility (Table 1). During the physical examination, compare findings to the contralateral uninjured knee and assess adja- cent joints for referral pain, including the hip and ankle.7 Steven Silverman, MD Michigan Head Pain and Neurological Institute, Ann Arbor, MI The continuing education activity in Topics in Pain Management is intended for clinical and academic physicians from the specialties of anesthesiology, neurology, psychiatry, physical and rehabilitative medicine, and neurosurgery, as well as residents in those fields Sahar Swidan, PharmD, BCPS and other practitioners interested in pain management. Pharmacy Solutions, Ann Arbor, MI Topics in Pain Management (ISSN 0882-5646) is published monthly by Wolters Kluwer Health, Inc. at 14700 Citicorp Drive, Bldg 3, Hagerstown, MD P. Sebastian Thomas, MD 21742. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or Email Syracuse, NY [email protected]. Visit our website at lww.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Priority postage paid at Hagerstown, MD, and at additional mailing offices. GST registration number: 895524239. POSTMASTER: Send address changes to Topics in Pain Management, Emily Wakefield, PsyD PO Box 1610, Hagerstown, MD 21740. Connecticut Children’s Medical Center, University of Publisher: Randi Davis Connecticut School of Medicine, Hartford, CT Subscription rates: Individual: US $399, international: $506. Institutional: US $990, international $1129. In-training: US $156 with no CME, international $179. Single copies: $95. Send bulk pricing requests to Publisher. COPYING: Contents of Topics in Pain Management are protected by copyright. Reproduction, photocopying, and storage or transmission by magnetic or electronic Marjorie Winters, BS, RN means are strictly prohibited. Violation of copyright will result in legal action, including civil and/ Michigan Head Pain and Neurological Institute, Ann Arbor, MI or criminal penalties. Permission to reproduce copies must be secured in writing; at the news- letter website (www.topicsinpainmanagement.com), select the article, and click “Request Permission” under “Article Tools” or e-mail [email protected]. For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For Steven Yarows, MD quantities of 500 or under, e-mail [email protected], call 1-866-903-6951, or fax 1-410-528- 4434. Chelsea Internal Medicine, Chelsea, MI PAID SUBSCRIBERS: Current issue and archives (from 1999) are now available FREE online at www.topicsinpainmanagement.com. Topics in Pain Management is independent and not affiliated with any organization, vendor Lonnie Zeltzer, MD or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All com- UCLA School of Medicine, Los Angeles, CA ments are for general guidance only; professional counsel should be sought for specific situa- tions. Editorial matters should be addressed to Anne Haddad, Associate Editor, Topics in Pain Management, 204 E. Lake Avenue, Baltimore, MD, 21212; E-mail: [email protected]. Topics in Pain Management is indexed by SIIC HINARI and Google Scholar. 2 ©2019 Wolters Kluwer Health, Inc. All rights reserved. TTPMv34n7.inddPMv34n7.indd 2 008/01/198/01/19 77:39:39 PPMM Topics in Pain Management February 2019 Table 1. Components of the Initial Evaluation of Knee Pain History Physical Examination Specific Mechanical Injuries History of knee pain, injury, or joint disease Observation of color, swelling, alignment, Integrity of the ACL: Lachman test, Medical history, comorbidities, and present medications deformity, gait, weight-bearing, wounds, pivot shift test Travel, exposures (eg, tick bite), and sexual contacts inflammation (calor, rubor, tumor, dolor) Involvement of other organ systems Occupation, sports, and functional abilities or Palpation for temperature and to detect Integrity of the MCL and LCL: varus limitations swelling, tenderness, joint effusion (patellar and valgus stress tests ballottement), masses, or tendon defects Mechanism of injury Range of motion (active and passive) Meniscal injury: combination of joint- Position of knee at time of injury and amount of Hypermobility line tenderness and results of Apley force/direction, and torsion test, McMurray test, Thessaly test, Onset of pain and swelling and Ege’s test Acuity of injury Neurovascular
Load more

Recommended publications
  • Effusion =S Fluid in Pleural Space (Outside of Lung) Fremitus - Pathophysiology • Fremitus: – Increased W/Consolidation (E.G
    General Part Head and Neck Cardiovascular Abdomen Lung Muscles Lung Exam • Includes Vital Signs & Cardiac Exam • 4 Elements (cardiac & abdominal too) – Observation – Palpation – Percussion – Auscultation Pulmonary Review of Systems • All organ systems have an ROS • Questions to uncover problems in area • Need to know right questions & what the responses might mean! Exposure Is Key – You Cant Examine What You Can’t See! Anatomy Of The Spine Cervical: 7 Vertebrae Thoracic: 12 Vertebrae Lumbar: 5 Vertebrae Sacrum: 5 Fused Vertebrae Note gentle curve ea segment Hammer & Nails icon indicates A Slide Describing Skills You Should Perform In Lab Spine Exam As Relates to the Thorax • W/patient standing, observe: – shape of spine. – Stand behind patient, bend @ waist – w/Scoliosis (curvature) one shoulder appears “higher” Pathologic Changes In Shape Of Spine – Can Affect Lung Function Scoliosis (curved to one side) Thoracic Kyphosis (bent forward) Observation • ? Ambulates w/out breathing difficulty? • Readily audible noises (e.g. wheezing)? • Appearance →? sitting up, leaning forward, inability to speak, pursed lips → significant compromise • ? Use of accessory muscles of neck (sternocleidomastoids, scalenes), inter-costals → significant compromise / Make Note of Chest Shape: Changes Can Give Insight into underlying Pathology Barrel Chested (hyperinflation secondary to emphysema) Examine Nails/Fingers: Sometimes Provides Clues to Pulmonary Disorders Cyanosis Nicotine Staining Clubbing Assorted other hand and arm abnormalities: Shape, color, deformity
    [Show full text]
  • Netter's Musculoskeletal Flash Cards, 1E
    Netter’s Musculoskeletal Flash Cards Jennifer Hart, PA-C, ATC Mark D. Miller, MD University of Virginia This page intentionally left blank Preface In a world dominated by electronics and gadgetry, learning from fl ash cards remains a reassuringly “tried and true” method of building knowledge. They taught us subtraction and multiplication tables when we were young, and here we use them to navigate the basics of musculoskeletal medicine. Netter illustrations are supplemented with clinical, radiographic, and arthroscopic images to review the most common musculoskeletal diseases. These cards provide the user with a steadfast tool for the very best kind of learning—that which is self directed. “Learning is not attained by chance, it must be sought for with ardor and attended to with diligence.” —Abigail Adams (1744–1818) “It’s that moment of dawning comprehension I live for!” —Calvin (Calvin and Hobbes) Jennifer Hart, PA-C, ATC Mark D. Miller, MD Netter’s Musculoskeletal Flash Cards 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 NETTER’S MUSCULOSKELETAL FLASH CARDS ISBN: 978-1-4160-4630-1 Copyright © 2008 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this book may be produced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publishers. Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing Department in Philadelphia PA, USA: phone 1-800-523-1649, ext. 3276 or (215) 239-3276; or e-mail [email protected].
    [Show full text]
  • Carpal-Instability-Slide-Summary.Pdf
    Carpal Instabilities Definition by IFSSH Orthopaedic Hand Conference Wrist is unstable only if it exhibits • symptomatic dysfunction Bernard F. Hearon, M.D. inability to bear loads Clinical Assistant Professor, Department of Surgery • University of Kansas School of Medicine - Wichita May 7, 2019 • abnormal carpal kinematics Garcia-Elias, JHS 1999 Carpal Instability Mayo Classification CID - Dissociative Wright, JHS (Br) 1994 Instability within carpal row usually due to intrinsic ligament injury • Carpal Instability Dissociative (CID) • Carpal Instability Non-Dissociative (CIND) • Scapholunate dissociation • Carpal Instability Adaptive (CIA) • Lunotriquetral dissociation • Carpal Instability Complex (CIC) • Scaphoid fracture Carpal Instability Carpal Instability CIND - Nondissociative Instability between carpal rows due CIA - Adaptive to extrinsic ligament injury Extra-carpal derangement causing carpal malalignment • CIND - Volar Intercalated Segment Instability (VISI) Midcarpal instability caused by malunited • CIND - Dorsal Intercalated fractures of the distal radius Segment Instability (DISI) Taleisnik, JHS 1984 • Combined CIND Carpal Instability Carpal Instability CIC - Complex Instability patterns with qualities of both CID and CIND patterns • Dorsal perilunate dislocations (lesser arc) Perilunate • Dorsal perilunate fracture-dislocations (greater arc injuries) Instability • Volar perilunate dislocations • Axial dislocations, fracture-dislocations Carpal Instability Carpal Instability Perilunate Dislocations Mayfield Classification Progressive
    [Show full text]
  • Disorders of the Knee
    DisordersDisorders ofof thethe KneeKnee PainPain Swelling,Swelling, effusioneffusion oror hemarthrosishemarthrosis LimitedLimited jointjoint motionmotion Screw home mechanism – pain, stiffness, fluid, muscular weakness, locking InstabilityInstability – giving way, laxity DeformityDeformity References: 1. Canale ST. Campbell’s operative orthopaedics. 10th edition 2003 Mosby, Inc. 2. Netter FH. The Netter collection of Medical illustrations – musculoskeletal system, Part I & II. 1997 Novartis Pharmaceuticals Corporation. 3. Magee DJ. Orthopedic Physical assessment. 2nd edition 1992 W. B. Saunders Company. 4. Hoppenfeld S. Physical examination of the spine and extremities. 1976 Appleton-century-crofts. AnteriorAnterior CruciateCruciate LigamentLigament Tibial insertion – broad, irregular, diamond-shaped area located directly in front of the intercondylar eminence Femoral attachment Femoral attachment Figure 43-24 In addition to their – semicircular area on the posteromedial synergistic functions, cruciate aspect of the lateral condyle and collateral ligaments exercise 33 mm in length basic antagonistic function 11 mm in diameter during rotation. A, In external Anteromedial bundle — tight in flexion rotation it is collateral ligaments that tighten and inhibit excessive Posterolateral bundle — tight in extension rotation by becoming crossed in 90% type I collagen space. B, In neutral rotation none 10% type III collagen of the four ligaments is under unusual tension. C, In internal Middle geniculate artery rotation collateral ligaments Fat
    [Show full text]
  • Meniscus Injury
    Introduction Role of menisci • Medial meniscus lesions are more common than 01 lateral meniscus because it is attached to the improving articular capsule that make it less mobile thus it cannot congruency and increasing easily to accommodate the abnormal stresses. the stability of the knee • In increasing age – gradual degeneration and change in the material properties of the menisci Meniscus controlling the complex thus splits and tears are more likely that usually associated with osteoarthritic articular damage or rolling and gliding actions of chondrocalcinosis. Injury the joint • In younger people - meniscal tears are usually the result of trauma, with a specific injury identified in distributing load during the history. movement Tear of Meniscus Pathology Pathology • Usually, meniscus more likely to tear along its Vertical tear Horizontal tear length than across its width because the Bucket-handle tear usually ‘degenerative’ or due to repetitive minor trauma meniscus consists mainly of circumferential the separated fragment remains attached front complex with the tear pattern lying in many collagen fibres held by a few radial strands. and back planes The torn portion can sometimes displace towards may be displaced or likely to displace • The meniscus is usually torn by a twisting the centre of the joint and becomes jammed If the loose piece of meniscus can be displaced, it between femur and tibia acts as a mechanical irritant, giving rise to force with the knee bent and taking weight. This causes a block to movement with the patient recurrent synovial effusion and mechanical describing a ‘locked knee’ symptoms • In middle life, tears can occur with relatively posterior or anterior horn tears Some are associated with meniscal cysts little force when fibrotic change has the very back or front of the meniscus is It is also suggested that synovial cells infiltrate into the vascular area between meniscus and restricted mobility of the meniscus.
    [Show full text]
  • Analysis of Rehabilitation Procedure Following Arthroplasty of the Knee with the Use of Complete Endoprosthesis
    © Med Sci Monit, 2011; 17(3): CR165-168 WWW.MEDSCIMONIT.COM PMID: 21358604 Clinical Research CR Received: 2010.10.01 Accepted: 2010.12.23 Analysis of rehabilitation procedure following Published: 2011.03.01 arthroplasty of the knee with the use of complete endoprosthesis Authors’ Contribution: Magdalena Wilk-Frańczuk¹,²ACDEF, Wiesław Tomaszewski3ACDEF, Jerzy Zemła²ABDEF, A Study Design Henryk Noga4DEF, Andrzej Czamara3ADEF B Data Collection C Statistical Analysis 1 Andrzej Frycz Modrzewski Cracow University, Cracow, Poland D Data Interpretation 2 Cracow Rehabilitation Centre, Cracow, Poland E Manuscript Preparation 3 College of Physiotherapy, Wroclaw, Poland F Literature Search 4 Endoscopic Surgery Clinic and Sport Clinic Żory, Żory, Poland G Funds Collection Source of support: Departmental sources Summary Background: The use of endoprosthesis in arthroplasty requires adaptation of rehabilitation procedures in or- der to reinstate the correct model of gait, which enables the patient to recover independence and full functionality in everyday life, which in turn results in an improvement in the quality of life. Material/Methods: We studied 33 patients following an initial total arthroplasty of the knee involving endoprosthesis. The patients were divided into two groups according to age. The range of movement within the knee joints was measured for all patients, along with muscle strength and the subjective sensation of pain on a VAS, and the time required to complete the ‘up and go’ test was measured. The gait model and movement ability were evaluated. The testing was conducted at baseline and after com- pletion of the rehabilitation exercise cycle. Results: No significant differences were noted between the groups in the tests of the range of movement in the operated joint or muscle strength acting on the knee joint.
    [Show full text]
  • Comparison of the Thesslay Test and Mcmurray Test: a Systematic
    py & Ph ra ys e i th c Alexanders et al.,Physiother Rehabil 2016, 1:1 a io l s R y e Journal of DOI: 10.4172/2573-0312.1000104 h h a P b f i o l i l t a ISSN:a 2573-0312 t n i r o u n o J Physiotherapy & Physical Rehabilitation Research Article Open Access Comparison of the Thesslay Test and McMurray Test: A Systematic Review of Comparative Diagnostic Studies Jenny Alexanders1*, Anna Anderson2, Sarah Henderson1 and Ulf Clausen3 1Sport, Health and Sciences Department, The University of Hull, Washburn Building, Cottingham Road, Hull, United Kingdom 2Leeds Teaching Hospitals, Beckett Street, Leeds, LS9 7TF, United Kingdom 3Dr Hill and Partners, Beverly Health Practice, Manor Road, Hull, HU17 7BZ, United Kingdom Abstract Background: The Thessaly test is a relatively recently developed meniscal test; therefore research compared to other meniscal tests is somewhat limited. In addition, a systematic review comparing the Thessaly’s test with a long standing test such as the McMurray test has not been previously conducted. Objective: To systematically identify and appraise all empirical studies comparing the diagnostic accuracy of the Thessaly test and McMurray test. Procedure: Eligible studies were identified through a rigorous search of ScienceDirect, CINAHL Plus, Pubmed, PEDro, EMBASE and Cochrane Library from January 2004 until August 2014. Full English reports of studies investigating the accuracy of the Thessaly test and McMurray test. Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) scores were completed on each selected article. Results: The Thessaly test reported to have higher diagnostic accuracy values (61-96%) compared to the McMurray test (56-84%).
    [Show full text]
  • Physical Esxam
    Pearls in the Musculoskeletal Exam Frank Caruso MPS, PA-C, EMT-P Skin, Bones, Hearts & Private Parts 2019 Examination Key Points • Area that needs to be examined, gown your patients - well exposed • Understand normal functional anatomy • Observe normal activity • Palpation • Range of Motion • Strength/neuro-vascular assessment • Special Tests General Exam Musculoskeletal Overview Physical Exam Preview Watch Your Patients Walk!! Inspection • Posture – Erectness – Symmetry – Alignment • Skin and subcutaneous tissues – Swelling – Redness – Masses Inspection • Extremities – Size – Deformities – Enlargement – Alignment – Contour – Symmetry Inspection • Muscles – Bilateral symmetry – Hypertrophy – Atrophy – Fasciculations – Spasms Palpation • Palpate bones, joints, and surrounding muscles for the following: – Heat – Tenderness – Swelling – Fluctuation – Crepitus – Resistance to pressure – Muscle tone Muscles • Size and strength affected by the following: – Genetics – Exercise – Nutrition • Muscles move joints through range of motion (ROM). Muscle Strength • Compare bilateral muscles – Strength – Symmetry – Equality – Resistance End Feel Think About It!! • The sensation the examiner feels in the joint as it reaches the end of the range of motion of each passive movement • Bone to bone: This is hard, unyielding – normal would be elbow extension. • Soft–tissue approximation: yielding compression that stops further movement – elbow and knee flexion. End Feel • Tissue stretch: hard – springy type of movement with a slight give – toward the end of range of motion – most common type of normal end feel : knee extension and metacarpophalangeal joint extension. Abnormal End Feel • Muscle spasm: invoked by movement with a sudden dramatic arrest of movement often accompanied by pain - sudden hard – “vibrant twang” • Capsular: Similar to tissue stretch but it does not occur where one would expect – range of motion usually reduced.
    [Show full text]
  • Evaluation and Management of Sports Injuries in Children
    2019 Frontiers in Pediatrics Sports Medicine Mini-Symposium Presented by MUSC Health Sports Medicine Sports Medicine Panel of Experts Michael J. Barr, PT, DPT, MSR Sports Medicine Manager MUSC Health Sports Medicine Alec DeCastro, MD Assistant Professor CAQ Sports Medicine Director, MUSC/Trident Family Medicine Residency MUSC Health Sports Medicine MUSC Department of Family Medicine Harris S. Slone, MD Associate Professor Orthopaedic Surgery and Sports Medicine MUSC Health Sports Medicine MUSC Department of Orthopaedics Sports Medicine Breakout Group Leaders Aaron Brown, ATC Athletic Trainer MUSC Health Sports Medicine Amelia Brown, MS, ATC Athletic Trainer MUSC Health Sports Medicine Brittney Lang, MS, ATC Athletic Trainer MUSC Health Sports Medicine Bobby Weisenberger, MS, ATC, PES Athletic Trainer MUSC Health Sports Medicine Sports Medicine Schedule Approximate Timeline: 2:00: Introduction – Michael Barr, PT, DPT, MSR – Sports Medicine Manager 2:05: Ankle Case Report – Harris Slone, MD 2:20: Knee Case Report – Harris Slone, MD 2:35: Shoulder Instability Case Report – Michael Barr, PT, DPT, MSR 2:50: Back Case Report – Alec DeCastro, MD 3:05: High BP Case Report – Alec DeCastro, MD 3:20: Hands On Practice of Exam Techniques – All + Athletic Trainers 3:50: Question/Answer Open Forum – All 4:00: End Sports Medicine Disclosers No relevant financial disclosers Sports Medicine Learning Objectives Learning Objectives: 1. Describe mechanisms of injury and clinical presentation for common pediatric sports related injuries of the ankle, knee, back and shoulder. 2. Demonstrate examination techniques to support the diagnosis of common pediatric sports related injuries of the ankle, knee, back and shoulder 3. Determine what imaging studies should be ordered and when to refer to a sports med/orthopaedic surgeon or to physical therapy 4.
    [Show full text]
  • Examination of the Knee
    Examination of the Knee The Examination For every joint of the lower extremity always begin with the patient in standing IN STANDING INSPECTION 1. Cutaneous Structures: Look for Erythema, scarring, bruising, and swelling in the following areas: a. Peripatellar grooves b. Suprapatellar bursa c. Prepatellar bursa d. Infrapatellar tendon e. Anserine bursa f. Popliteal fossa 2. Muscle & Soft Tissue: a. Quadriceps atrophy b. Hamstring atrophy c. Calf atrophy 3. Bones & Alignment: a. Patella position (Alta, Baha, Winking, Frog eyed), b. Varus or Valgus alignment c. Flexion contracture or Genu recurvatum RANGE OF MOTION - ACTIVE Standing is the best opportunity to assess active range of motion of the knee. 1. Ask the patient to squat into a deep knee bend. Both knees should bend symmetrically. 2. Ask the patient to then stand and extend the knee fully – lock the knee. The knee should straighten to 0 degrees of extension. Some people have increased extension referred to as genu recurvatum. GAIT 1. Look for a short stance phase on the affected limb and an awkward gait if a concomitant leg length discrepancy 2. Look for turning on block 3. Screening 1. Walk on the toes 2. Walk on the heels 3. Squat down – Active Range of Motion testing SPECIAL TESTS 1. Leg Length Discrepancy a. Look at patients back for evidence of a functional scoliosis b. Place your hands on the patients Iliac crests looking for inequality which may mean a leg length discrepancy IN SITTING NEUROLOGIC EXAMINATION 1. Test the reflexes a. L4 – Quadriceps reflex VASCULAR EXAMINATION 1. Feel for the posterior tibial artery SUPINE POSITION INSPECTION 1.
    [Show full text]
  • SIMMONDS TEST:  Patient Is Prone  Doctor Flexes the Patients Knee to 90 Degrees  Doctor Squeezes the Patient’S Calf
    Clinical Orthopedic Testing Review SIMMONDS TEST: Patient is prone Doctor flexes the patients knee to 90 degrees Doctor squeezes the patient’s calf. Classical response: Failure of ankle plantarflexion Classical Importance= torn Achilles tendon Test is done bilaterally ACHILLES TAP: Patient is prone Doctor flexes the patient’s knee to 90 degree Doctor dorsiflexes the ankle and then strikes the Achilles tendon with a percussion hammer Classical response: Plantar response Classical Importance= Intact Achilles tendon Test is done bilaterally FOOT DRAWER TEST: Patient is supine with their ankles off the edge of the examination table Doctor grasps the heel of the ankle being tested with one hand and the tibia just above the ankle with the other. Doctor applies and anterior to posterior and then a posterior to anterior sheer force. Classical response: Anterior or posterior translation of the ankle Classical Importance= Anterior talofibular or posterior talofibular ligament laxity. Test is done bilaterally LATERAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other. Doctor rotates the foot into inversion Classical response: Excessive inversion Classical Importance= Anterior talofibular ligament sprain Test is done bilaterally MEDIAL STABILITY TEST: Patient is supine Doctor grasps the tibia with one hand and the foot with the other Doctor rotates the foot into eversion Classical response: Excessive eversion Classical Importance= Deltoid ligament sprain Test is done bilaterally 1 Clinical Orthopedic Testing Review KLEIGER’S TEST: Patient is seated with the legs and feet dangling off the edge of the examination table. Doctor grasps the patient’s foot while stabilizing the tibia with the other hand Doctor pulls the ankle laterally.
    [Show full text]
  • Knee Pain in Children: Part I: Evaluation
    Knee Pain in Children: Part I: Evaluation Michael Wolf, MD* *Pediatrics and Orthopedic Surgery, St Christopher’s Hospital for Children, Philadelphia, PA. Practice Gap Clinicians who evaluate knee pain must understand how the history and physical examination findings direct the diagnostic process and subsequent management. Objectives After reading this article, the reader should be able to: 1. Obtain an appropriate history and perform a thorough physical examination of a patient presenting with knee pain. 2. Employ an algorithm based on history and physical findings to direct further evaluation and management. HISTORY Obtaining a thorough patient history is crucial in identifying the cause of knee pain in a child (Table). For example, a history of significant swelling without trauma suggests bacterial infection, inflammatory conditions, or less likely, intra- articular derangement. A history of swelling after trauma is concerning for potential intra-articular derangement. A report of warmth or erythema merits consideration of bacterial in- fection or inflammatory conditions, and mechanical symptoms (eg, lock- ing, catching, instability) should prompt consideration of intra-articular derangement. Nighttime pain and systemic symptoms (eg, fever, sweats, night sweats, anorexia, malaise, fatigue, weight loss) are associated with bacterial infections, inflammatory conditions, benign and malignant musculoskeletal tumors, and other systemic malignancies. A history of rash or known systemic inflammatory conditions, such as systemic lupus erythematosus or inflammatory bowel disease, should raise suspicion for inflammatory arthritis. Ascertaining the location of the pain also can aid in determining the cause of knee pain. Anterior pain suggests patellofemoral syndrome or instability, quad- riceps or patellar tendinopathy, prepatellar bursitis, or apophysitis (patellar or tibial tubercle).
    [Show full text]