Transcript The Knee

Sports Medicine
Workshop
Shoulder Problem Evaluation




Second most common
musculoskeletal complaint
Difficult joint to examine
Multidirectional range of motionUNIQUE!
Shoulder injury can affect nearly
every sport and many daily activities
Objectives

Review pertinent
anatomy

Discuss common
pathology

Discuss historical
clues to diagnosis

Select cases

Physical exam in small
group discussions
Bony Anatomy
Anterior
Bony Anatomy
Anterior and Posterior
Radiographic Anatomy
Where do things go wrong??
Fractures
Where do things go wrong??
Dislocations and Separations
Dislocations and separations are protected
by both “static” and “dynamic”
stabilizers…
Where do things go wrong??
Dislocations and Separations
Oh, yeah…Arthritis can happen at these joints,
too…
Glenohumeral Joint

Shallow (“golf ball sitting on a tee”)
• Inherently unstable (maximizes ROM)

Static stabilizers
• glenohumeral ligaments, glenoid labrum and
capsule

Dynamic stabilizers
• Predominantly rotator cuff muscles
• Also scapular stabilizers

Trapezius, leavator scapulae, serratus anterior,
rhomboids
Bony Anatomy
“Static Stabilizers”

What goes wrong…
Besides separations and dislocations??
Instability
LABRUM
What goes wrong?
Tears and tendonopathies
The Rotator Cuff Muscles
“dynamic stabilizers”
The Rotator Cuff Muscles: SITS
• Supraspinatus
ABD
• Infraspinatus
ER
• Teres minor
ER
• Supscapularis
IR
Depress humeral head against glenoid to allow full
abduction
Finally…the subacromial space
What can go wrong???
Impingement!!!!!
!!
Impingement
Other Anatomy
• Deltoid
• Rotator cuff
• Teres major
• Latissimus dorsi
• Biceps
• Pectoralis muscles
Shoulder Anatomy
Don’t forget the
scapular stabilizer muscles
So…what causes shoulder pain?

Impingement

Labrum and biceps pathology
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A-C joint pathology
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Rotator Cuff Injury

Instability
things…
Among other
Clinical Exam
History
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Pain
Acute
Chronic
Weakness
Deformity
Clinical Exam
History

Single event

Repetitive overload

Instability
• Does it feel like it’s
going to come out?

Catching/Locking
Clinical Exam
History

Sport / Occupation

Previous injury
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Previous treatment

Other joints involved

Disability
Physical Exam: Big 6
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Inspection
Palpation
Range of Motion
Strength
Neurovascular
Special Tests
Special Tests
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Impingement
Rotator Cuff
Integrity

Labrum and Biceps

AC (SC) Joints

Instability
Physical Exam

The physical exam will be
demonstrated during small group
discussions…
Which rotator cuff muscle(s) are
responsible for external rotation
1.
Supraspinatus
2.
Infraspinatus
3.
Subscapularis
4.
Teres Minor
5.
Both 2 and 4
The apex (bottom) of the scapula is
at what level of the spine?
1.
2.
3.
4.
5.
C7
T3
T7
T12
L4
Case #1
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22-year-old male
rugby player falls
onto his right
shoulder while
being tackled
Severe pain on top
of his right
shoulder
Case #1


Notable deformity
over superior
shoulder
Painful range of
motion
• Unable to lift right
arm above waist
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Special Tests??
Diagnosis???
Acromioclavicular (A-C) Sprain

Special Tests
• Shear Test
• Cross Arm Test
• A-C Palpation
• Resisted Extension
• Active compression test
Acromioclavicular (A-C) Sprain



Damage to A-C
joint ligaments
Pain and/or
deformity over A-C
joint
Graded I-VI
• I-III usually treated
non-operatively
• IV-VI referred to
orthopedic surgery
AC Joint Sprain
Treatment
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
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Analgesics, ice prn
Sling for as long as needed
Physical Therapy
• ROM restoration
• Gradual strength exercise
• Return to sport activity as
tolerated
Case #2
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24-year-old male
handball player
Fell onto his shoulder
after being pushed
Intense pain
Hand is tingling and
arm feels like it’s
hanging
X-rays
X RAYS
DIAGNOSIS???
Shoulder Dislocation/Anterior
Instability



Humeral head
dislocates from
glenoid fossa
Almost always
anterior (95%)
Usually traumatic
with injury to
capsule-labrum
complex
Shoulder Dislocation/Anterior
Instability

Treatment
• Reduction of dislocation
• Protection & rehab, rehab, rehab
• Most will have future dislocations
and/or instability

At least 70%!!! (young)
• May require surgical
tightening/repair of the
capsule/labrum complex
Special Tests
Glenoid Labrum and Instability
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Biceps Load I and II
Kim Test
Jerk Test
Active-Compression Test (O’Brien)
Crank Test
Apprehension Test
Relocation Test
Load and Shift
Sulcas Sign
Which of the following structures
can be “impinged”?
1.
2.
3.
4.
30
Biceps tendon
Subacromial
Bursa
Rotator Cuff
Tendons
All of the above
25%
25%
25%
25%
10
0
0
1
2
3
4
Case #3
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35-year-old male
tennis player
Shoulder pain
exacerbated by
practicing serves
Develops dull,
aching pain in right
shoulder
SHOULDER PAIN
Physical Exam
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Tenderness to palpation anterior
shoulder
Pain with abduction starting around
90 degrees
Unable to lift arm past 120 degrees
Pain with forward flexion at 90-120
degrees
Special Tests??? Diagnosis???
Shoulder Pain
Physical Exam

Hawkin’s positive

Neer’s positive
IMPINGEMENT???
Impingement as a Clinical Sign



Repetitive overhead
activities
Subacromial bursa
and/or rotator cuff
impinged between
acromion & humerus
Physical therapy,
activity modification
+/- medications
Diagnoses associated with clinical
sign of Rotator Cuff Impingement:
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Subacromial bone spurs and / or bursal
hypertrophy
AC joint arthrosis and /or bone spurs
Rotator cuff disease
Superior labral injury
Glenohumeral instability
Scapular dyskinesis
Biceps tendinopathy
A diagnostic injection sometimes helps to
clarify the diagnosis
Case #4
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45-year-old weight
lifter
Caught bar as it was
falling off his shoulder
Sudden pain
Severe weakness left
shoulder
Worse with overhead
activities; while
sleeping at night
Pain in anterior lateral
shoulder
Special tests?
Case #4
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Drop Arm Test Positive

External Rotation Lag
Sign positive

Weakness with Empty
Can Sign

Normal bear hug and
belly press tests…

Diagnosis?????
Rotator Cuff Tear
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Supraspinatus tendon most common
Acute trauma or chronic
tendinopathy
Treatment dependent upon
age/activity
• Young, active usually require operative
treatment
• Older, low-activity usually respond to
non-operative treatment
Case #5
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42-year-old female with dull pain
right shoulder
Pain is diffuse in nature
Sometimes spreads to between
shoulder blades
Seems worse at night
Physical Exam
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Obese, pleasant female
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Diffuse pain
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Normal shoulder exam
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Not able to reproduce pain during exam
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What else do you want to do???
Shoulder pain isn’t always the
shoulder!!
Get more history…
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Gall bladder disease
Peptic Ulcer Disease
Cervical radiculopathy
Cardiac ischemia
Pulmonary conditions
• ie Pancoast’s tumor, Pneumonia
In the human body, which is the
most incredible joint?
1.
2.
3.
4.
5.
PIP
Knee
Ankle
Shoulder
None of the
above
20%
1
20%
2
20%
20%
3
4
20%
5
Case #6
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40-year-old male
Recently shoveled
16” of snow
Can hardly lift left
arm due to pain
Special Tests?
Diagnosis?
Biceps Tendonopathy
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Speed Test
Yergason Test
Direct palpation
Biceps Tendonopathies
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Repetitive overhead
activity
Repetitive forearm
flexion/supination
Difficult to discern from
rotator cuff tendinopathy
or impingement
Conclusion
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Shoulder injuries are common.
Knowledge of the anatomy is crucial
to correct patho-anatomic diagnosis.
Impingement is a clinical sign, not a
diagnosis.
Don’t forget about medical causes.
Physical Exam
Inspection
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

Front & back
Height of
shoulder and
scapulae
Muscle atrophy,
asymmetry
Physical Exam
Range of Motion

Abduction 0-180o
Physical Exam
Range of Motion

Forward flexion:
• 0o – 180o
Physical Exam
Range of Motion

Extension
• 0o – 40 to 60o
Physical Exam
Range of Motion

Internal rotation
• T5 segment

External rotation
• 80-90o
Physical Exam
Strength

Empty can test
• 30o angle
• Steady downward pressure
• Tests supraspinatus strength and pain
Physical Exam
Strength

Resisted external
rotation
• Tests infraspinatus,
teres minor
strength
Physical Exam
Strength of Subscapularis
Liftoff test
test
Belly press
Cross-Arm Adduction Test
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AC joint pathology
Arm flexed to 90°
Hyperadduct arm
across body as far
as possible
Pain in AC = (+)
test
A-C Shear Test
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Interlock fingers
with hand on distal
clavicle and spine
of scapula
Pain in A-C joint
when hands
squeezed together
= (+) test
Sulcus Sign
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Inferior instability
Arm relaxed in
neutral position,
pull downward at
elbow
(+) test = sulcus
at infra-acromial
area
• compare to
unaffected side
Apprehension Test
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Anterior instability
Shoulder at 90°
abducted, slight
anterior pressure &
External rotation
(+) test =
dislocation
apprehension
• some false (+)
Relocation Test
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Perform after
positive
apprehension test
Apply post force
over humeral head
during external
rotation (ER)
(+) test =
increased ER
tolerance
Load & Shift Test
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Test for multidirectional instability
Grasp humeral head, slide anteriorly and
posteriorly while securing rest of shoulder
(+) if greater than 50% displacement (graded
1-3)
Impingement Signs
Hawkins
Neer
Drop Arm Test
Suggestive of Rotator Cuff Tear
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Passive abduction
to 90°
Instruct patient to
slowly lower arm
At 90° abducted
arm will suddenly
drop, may need to
add slight pressure
(+) drop = (+)
test
Speed’s Test
Biceps Tendinopathy
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Long head of biceps
tendonitis
Fwd flex to 90°, abd
10°, full supination
Apply downward
force to distal arm
Pain = (+) test
• weakness w/o
pain = muscle
weakness or
rupture
O’Brien’s Active Compression
SLAP lesion (Superior Labrum Antero-Posterior)
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

Labral/AC
pathology
Arm flexed to 90°,
elbow extended,
adduct 10-15°,
resist downward
force
+ if AC pain or
internal pain/click
O’Brien’s Active Compression
SLAP lesion

Supination should
be pain free
(decreased pain)
Crank Test
Labral injury
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
Glenoid labrum
tear
Abduct arm to
160°, pt is supine
or upright, elbow
secured with one
hand axial load at
shoulder with other
(+) if
audible/painful
catch/grind is
Knee Problems
Anatomy Review

Femur
Tibia
• Medial & lateral
Condyles
 Epicondyles
• Gerdy’s
tubercle
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• Trochlear
groove
Pes anserine
area
Intercondylar
notch
• Tibial
tuberosity
• Tibial plateau
• Tibial spines
Patella
• Superior pole (base)
Fibula
• Inferior pole (apex)
• Head
Medial & lateral facets
• Neck
Anatomy – Major Ligaments & Tendons

Quadriceps tendon
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Patellar tendon

Medial & lateral patellar
retinaculua

MCL
LCL
ACL and PCL
Iliotibial band (ITB)
Anatomy – Menisci of the Knee
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Medial meniscus
Lateral meniscus
• Meniscal ligaments
• Functions of the
menisci
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Meniscal zones
• White-white
• Red-white
• Red-red
Knee Exam Overview
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Inspection
Palpation
Range of Motion
Strength
Neurovascular
Special Tests
Case 1 – Medial Right Knee Pain
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16yo HS soccer
player, previously
healthy
Tackled from right
side while running
Immediate onset of
medial jt line pain
Delayed onset local
medial edema,
stiffness
Able to bear weight
Key Questions in the History
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Mechanism of Injury?
Acute or Chronic?
Location and level of pain?
Able to walk?
Mechanical Symptoms? (Locking,
popping, catching?)
Associated instability?
Swelling?
Previous injuries or surgeries?
Case 1 - Exam
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Inspection: Mild medial knee edema
Palpation: + ttp medial knee
ROM: can’t bend >80d
Strength: mildly decreased
Neurovascular: normal
Special tests:
• Neg Lachman, Anterior Drawer, McMurray,
varus stress

+ mild increased gap on valgus stress
(compared to left) with good endpoint
Special Tests - ACL Injury

Lachman Test
Special Tests - PCL Injury
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Posterior Drawer Test
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Sag Sign
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Quad-Active Test
Varus/Valgus stress for
LCL and MCL Injury
Features that should prompt an
xray after acute knee injury include:
e
he
ab
ov
55
of
t
Al
l
<1
8o
r>
TT
ad
Ag
e
he
ar
Fib
ul
Pa
t
el
la
TT
P
P
90
d
’t
fle
x>
gh
t
ei
Ca
n
6.
rw
5.
be
a
4.
to
3.
17% 17% 17% 17% 17% 17%
bl
e
2.
Unable to bear
weight
Can’t flex >90d
Patella TTP
Fibular head
TTP
Age <18 or
>55
All of the above
Un
a
1.
5 Ottawa Knee Rules
i.e. When to order a knee xray after acute injury
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Age > 55 or < 18
Unable to walk
TTP on PATELLA
TTP on FIBULAR HEAD
Unable to flex 90 deg
Case 1 - Imaging
Case 1 – Differential Diagnosis
More Likely

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Meniscal Tear
Ligamentous Injury
• Which ligament?
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ACL
PCL
MCL
LCL
Muscle Strain
Less Likely

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Fracture
Patellofemoral Pain
Plica
MCL Sprain
What grade of sprain is likely
present of the MCL?
25%
1.
25%
2.
25%
3.
25%
4.
Grade
Grade
Grade
Grade
1:
2:
3:
4:
no laxity, but hurts
mild laxity, still intact
complete tear
hurts like *^%*
MCL Sprain

Treatment?
• RICE
• Relative Rest
• Hinge Brace only if unstable on exam
• Achieve full ROM
• Progressive Strengthening
• Neuromuscular Control (Balance
exercises)
• Functional Exercises (Sport-specific)
Case 2
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56 yo retired Army LTC
15 years worsening L>R knee pain
Former parachutist, no specific
trauma
No previous knee surgeries
Stiffness worse in morning
Pain is worse with activity, better
with rest
Case 2 – Key Questions
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Mechanism of Injury?
Acute or Chronic?
Where/how bad is pain?
Mechanical Symptoms?
(Locking, popping,
catching?)
Associated instability?
Swelling?
Previous injuries or
surgeries?
What makes it worse?
What makes it better?
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Insidious Onset
Chronic
Difficult to localize; mild
No
None
Occasional
Lots of “Bad Landings” No
surgery
Activity
Rest
Case 2 – Physical Exam

Inspection:
• Genu varus
• Bony enlargement at Med/Lat joint lines

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Palp: Posterior medial joint line ttp
ROM: Decreased flexion, 110 deg, mild
crepitus
Strength: normal
Neurovascular: normal
Special Tests: no ligamentous laxity, neg
meniscal tests
Special Tests - Meniscal Injuries

Joint line tenderness

McMurray Tests
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Thessaly test
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Bounce-home test

Full Squat
Case 2 – Plain Films
Joint space narrowing
Subchondral Sclerosis
Osteophytes
Subchondral Cysts
What is your diagnosis?
25%
25%
or
m
tu
Bo
ne
Os
te
o
ar
th
rit
i
s
m
e
25%
yn
dr
o
as
Pl
ic
4.
r
3.
25%
te
a
2.
Meniscal tear
Plica syndrome
Osteoarthritis
Bone tumor
M
en
is c
al
1.
Osteoarthritis

Nonpharmacologic
Treatment:
• Nonpainful aerobic
activity
• Weight loss
• Physical Therapy

Improve ROM, increase
strength
• Bracing

Pharmacologic
Treatment:
• APAP
• Supplements

•
•
•
•
Glucosamine and
Chondroitin
NSAIDs, COX-2’s
Tramadol
Viscosupplementation
Intrarticular Steroids
Case 3
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31 year old female, L knee pain
Recreational runner
Localizes pain to front of knee
No trauma, insidious onset
Localizes pain “around kneecap”
Worse with stairs
Worse after prolonged sitting
Knee occasionally “gives out”
Case 3 – Key Questions
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Mechanism of Injury?
Acute or Chronic?
Where is the pain?
Mechanical
Symptoms? (Locking,
popping, catching?)
Associated instability?
Swelling?
Previous injuries or
surgeries?
What makes it worse?
What makes it better?

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Insidious Onset
Chronic
Anterior knee
No, but sometimes
gives out
None
None
None
Running, Stairs
Multiple days of rest
Physical Exam

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
Inspection: mild genu valgus
Palpation: TTP lateral > medial patellar
facets
ROM: full w/o pain
Strength: normal
Neurovascular: normal
Special Tests:
• + patellar grind
• Decreased patellar glide
• Inflexible hamstrings (Popliteal angle)
Patellofemoral Joint Exam
Patellofemoral Joint Exam
Patellar Grind Test
Case 3 – Plain Films
Lateral
AP
Case 3 – Plain Films
Sunrise
Tunnel
What’s your diagnosis?
e
yn
dr
o
as
Pl
ic
al
sy
n
m
dr
om
e
y
or
lo
fe
m
el
Pa
t
Pa
t
el
lar
in
st
ab
ilit
hy
op
at
4.
te
nd
in
3.
25% 25% 25% 25%
el
lar
2.
Patellar
tendinopathy
Patellar instability
Patellofemoral
syndrome
Plica syndrome
Pa
t
1.
Patellofemoral Syndrome

Treatment:
• Relative rest; non-painful aerobics
• Physical Therapy



Improve Quad/Hamstring flexibility
Quad, Hip abductor strengthening
Core strengthening
• Patellar stabilization brace/taping
• Foot orthotics
• Surgery (last-ditch effort)
Case 4




34 yo Army MAJ training for
1st marathon
Atraumatic onset of R
lateral knee pain 1 week
ago after 10 mile run
Sharp burning pain
Better with rest, returns
with running
Case 4 – Key Questions


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
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


Mechanism of Injury?
Acute or Chronic?
Where is the pain?
Mechanical
Symptoms? (Locking,
popping, catching?)
Associated instability?
Swelling?
Previous injuries or
surgeries?
What makes it worse?
What makes it better?









Insidious Onset
Acute
Lateral knee
No, but sometimes
gives out
None
None
None
Running
Multiple days of rest
Physical Exam


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
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
Inspection: normal
Palpation: TTP over lateral femoral
condyle
ROM: full
Strength: normal
Neurovascular: normal
Special tests:
• + Noble test
• Tight on Ober test
Ober test
Noble test
What’s your diagnosis?
Ili
ot
ib
ia
in
sp
ra
LC
L
dr
om
lb
an
d
sy
n
en
is c
al
e
te
ar
s
M
4.
rit
i
3.
25% 25% 25% 25%
rth
2.
Osteoarthritis
Meniscal tear
Iliotibial band
syndrome
LCL sprain
Os
te
oa
1.
Iliotibial Band Syndrome

Treatment:
• Ice massage, pain meds
• Relative Rest; nonpainful activity
• Physical Therapy



Specific ITB stretches
Hip abductor strengthening
Core strengthening (Gluteus Medius)
• Slow return to activity
• Extrinsic factors: shoes, running
surface, training errors
What the heck is a Plica?
se
Lo
o
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ta
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Congenital
thickening of joint
capsule
Redundant meniscus
Loose piece of intraarticular cartilage
Figment of my
imagination
Co
ng
e
1.
Plica Syndrome?
Special Tests - ACL Injury

Lachman Test
• Knee flexed to 15-30 degrees
• Stabilize distal femur
• Anteriorly translate tibia on
femur
• Watch & feel for amount of
translation & end point

Pivot Shift
Special Tests - PCL Injury

Posterior Drawer Test
• Knee flexed to 90 degrees
• Posteriorly translate tibia on
femur
• Watch & feel for amount of
translation & end point

Sag Sign
• Knees flexed, quads relaxed
 compare both sides
• Look for tibial posterior “sag”
relative to femur

Quad-Active Test
• Knee flexed; hamstrings fully
relaxed
• Slide foot along table (quad
active)
• Observe for anterior relocation
Special Tests - MCL Injury

Valgus Stress Testing
• Knee flexed to 30 degrees

Relax ACL/PCL & joint
capsule
• Valgus stress applied to knee
• Look and feel for translation
and endpoint
• Compare to uninjured side
• May repeat with knee in full
extension
Special Tests - LCL Injury

Varus Stress
Testing
• Same test as
valgus stress
testing
• Except applying a
varus stress
instead
• LCL, IT band, &
PLC are tested
Special Tests - Meniscal Injuries

Joint line tenderness

Full Squat

McMurray Tests

Thessaly test

Bounce-home test
McMurray test for
Meniscal injury



Test Med and Lat meniscus
separately
3 concurrent maneuvers:
• Grind it (Rotate tibia
AWAY from it)
• Crunch it (varus or
valgus)
• Pinch it (flex/extend
knee)
Positive: Painful “pop”
Special Tests - Meniscal Injuries

Thessaly Test
• Pt stands on
affected leg
• Knee bent at 20
degrees
• Examiner holds pt’s
hands and rotates
pt to both sides

Meniscal grind
• Positive test: pain,
painful click.
Anterior Knee Exam
Palpation of patellar
facets


Glide and lift patella
medially & laterally
Palpate undersurface
of patella for
tenderness
Patellar Exam
• Patellar Glide


Knee in extension, relaxed
Medial & lateral patellar
displacement
• Measured in quadrants


Normal: 1-2 quadrants
Patellar Apprehension

Lateral patellar displacement
 patient apprehension
or guarding
Anterior Knee Exam
Patellar Grind Test



Knee 10 deg flexion
Glide patella distally,
and firmly compress
patella against
trochlear groove
Active quadriceps
contraction  pain
Special Tests – Ober’s Test




Lateral decubitus with
testing side up, testing
knee flexed
Adduct and fully flex hip 
Abduct, externally rotate,
& extend hip
Slowly release support
against gravity from leg,
allowing gravity to take leg
towards table
Positive test: leg remains
abducted despite examiner
releasing leg
Special Tests

Noble’s test
• Palpate lateral
femoral condyle
• Flex and Extend
Knee
• + Test is pain at
site of palpation