DIFFERENTIAL DIAGNOSIS OF ANTERIOR KNEE PAIN IN YOUNG PATIENTS Differential diagnosis of anterior knee pain in the young patient Diagnosis Typical patient Clinical features Patellofemoral Patellar Osgood-Schlatter ‘syndrome tendonitis disease Young female Preadolescent athletes adolescent athletes Recent growth spurt © Subacute to Episodic pain | + t Pain with sports, chronic pain &tendemess | relieved by rest t with squatting, | at inferior o Teena’. running, patella swelling at tibial prolonged sitting, fibers using stairs * Patellofemoral compression testSPECIAL TESTS FOR KNEE EXAMINATION Special tests for knee examination Vaigus stress test * Place 1 hand above knee along lateral thigh. Place the other along medial leg & apply outward pressure along calf * Lexity indicates MCL injury Varus stress test + Place 1 hand above knee along medial thigh. Place the ‘other along lateral leg & apply inward pressure along calf * Laxity indicates LCL injury Anterior drawer test ‘+ Have patient lie supine with knee flexed at 90 degrees Caused by forceful hyperextension of knee or a non-contact torsional injury during deceleration Rapid onset hemarthrosis is typical « Place knee at 30 degrees flexion Stabilize distal femur with 1 hand & pull proximal tibia anteriorly with the other Significant anterior displacement of tibia with either test indicates ACL injury Posterior drawer test + Flex knee to 90 degrees & stabilize foot ‘© Grasp tibia with both hands & push posteriorly ‘* Significant displacement indicates PCL injury Posterior sag test ‘+ Place patient supine with hips flexed to 45 degrees, knees flexed to 90 degrees & feet flat on table ‘PCL injury causes affected tibia to sag backward relative to femur Can occur in athletes due to rapid Thessaly test direction changes—subacute or + Patient stands on 1 leg with knee flexed 20 degrees chronic locking oF poy * Pain or locking with internal &/or external knee rotation sensation—acute symptoms are a a usually mild—effusions possible but Apley test ; » With patient prone & knee flexed to 90 degrees, stabilize hesietineais eae patient’ thigh with examiner's knee or hand + Pross patient's hee! directly toward floor while internally & ‘externally rotating foot + Focal pain with compression suggests meniscal tear ‘McMurray test * Passive knoe flexion & extension while placing examiner's thumb & index finger on medial & lateral joint lines * Clicking with passive movements or mediai/ateral rotation Suggests meniscal tear 40 Or locking may also be palpableANTERIOR CRUCIATE LIGAMENT INJURY Features of anterior cruciate ligament injury Injury * Rapid deceleration or direction changes mechanisms | « Pivoting on lower extremity with foot planted * Pain: rapid onset, may be severe + A “popping” sensation at the time of injury * Significant swelling (effusion/hemarthrosis) + Joint instability ination | + Anterior laxity of tibia relative to femur (anterior finding drawer test, Lachman test) F cee | tape mementos Treatment | * RICE (rest, ice, compression, elevation) measures © 4/- SurgeryMENISCAL TEAR ‘+ Younger patients: Rotational force on planted foot, ‘+ Older patients: Degeneration of meniscal cartilage * Acute “popping” sensation Catching, locking, reduced range of motion ‘Siow-onset joint effusion Joint line tendemess Pain or catching in provocative tests (Thessaly, McMurray) ‘© Mild symptoms, older patients: Rest, activity modification + Porsistont symptoms, impaired activity: Surgery reduce the risk of further joint injuryCAUSES OF LOW BACK PAIN Common causes of low back pain Muscle strain pain can also radiate to buttocks and Compression fracture Older age Older age ‘More common in women ‘Traumaifall (may be minor) Condition CCM Chee, posterior thigh but pain = : ae below knee is characteristic (muscle strain, spasm, | + Negative straight leg raise Diterietey oes degenerative arthitis) |. possible paraspinal tendemess Hands aociaus! Radiculopathy (usually L4-L5) Radiation below the knee. pulposus! Possible positive straight log raise Crossed straight leg raise test is disk disease Possible neurologic deficits also specific Musculoskeletal if oi aka wari Better with spine flexion ae Worse with extension Inflammatory ana Metastatic cancer to inioclioon Osteomyelitis, discits, abscess Better with activity or exercise 'No improvement with rest Gradual onset HLA-827 present History of malignancy Age>s0 Worse at night Unintentional weight loss Cauda equina syndrome (weakness, urine retention/incontinence, saddie anesthesia) Recent infection WV drug abuse Diabetes Fever, exquisite tenderness Immune mediated disorder—affects ligamentous insertion site (enthesitis)—gradual onset of LBP and progressive stiffness—causes destruction of articular cartilage esp. sacroiliac joint (sacroilitis) and apophyseal joints of spine Constant—not relieved by rest Generally occurs in pts with recent overlying soft tissue infection or bacteremia—CRP and ESR usually 1 point