Knee Joint Differential

Diagnosis
Dr Shakir Ullah
 Subjective Examintion
• Pain in right knee , turning to the right what structure may cause the pain ?
• Pain in right knee , turning to the left what structure may cause the pain ?
• Knee buckling, if patient knows the buckling , what structure may involved ?
• Knee buckling, if patient doesn't know the buckling , what structure may involved ?
• Locking ,what structure may be involved
• Extreme flexion what structure may be involved
• In extreme extension what structure may be involved
Review the body chart and subjective information.
A 26 years female with knee pain
 BOS:

• Pain increased (left>>Right) with walking (especially hills), stairs,

prolonged sitting, squatting and cycling. Pain settled quickly back to
resting level with rest therefore was considered non-irritable.
 24 Hour:

• Pain was less in the mornings after rest and increased proportional to
aggravating activities throughout the day. Sue required panadeine
occasionally when the pain was severe. She did not report waking during
the night.
 Functionally/Occupation:
• She ceased aerobics and netball due to pain.
 Special Questions:

• X-ray results were NAD

• General health was ✓✓
• Tablets: NSAID Wt Loss: Nil
 Current History:

• An acute exacerbation occurred in her left knee 6 months ago due to

repeated stepping up on stairs at her office. At this stage there was acute
left knee pain and swelling. She consulted ORTHOPAEDIC DOCTOR,
who advised her to cease work and support the knee with a bandage.
Within 3 days, the pain increased and she was referred to a specialist at
the hospital where X-rays were taken. She was then referred for
physiotherapy. By the time she presented, She was in the subacute phase
with swelling having resolved and pain subsided over the previous 2
months.
 Past History:

• She reported a 20-year duration of symptoms possibly related to sports

during school. She recalls one episode 12 years ago whilst playing netball
where the knee felt as though it popped out but seemed ok afterwards. She
remembers some swelling and pain but it settled within a few weeks
without treatment.
 List the most likely possibilities to consider for the anterior and posterior knee pains.

 
 

Anterior: -
• Patello-femoral syndrome - Chondromalacia patellae - Osteoarthritis pat-
fem joint - Referral from Tib-fem joint - Overuse/inflammation specific
local structures - Bursitis, Patellar tendinitis, Fat pad irritation
 Posterior: -

• Posterior capsule - Biceps femoris tendonitis - Popliteal bursitis

• - Adverse mechanical tension - Referred from tib-fem joint  
• ACL/PCL
What is Chondromalacia patellae? How is it caused?
What is Patello-femoral syndrome?
What is the difference between CMP and
P/F syndrome?
 What subjective findings would support chondromalacia patellae?
 

• - Patient age and sex

• - Area, depth and quality of pain (diffuse pain anterior knee)
• - BOS / aggravating activities - Symptoms: giving way, clicking, grating.
• - Xray often normal (in later stage - degenerative changes would be noted)
• - Mechanism of injury - History of injury / subluxation - That
compression made the pathology worse.
What are the implications of the following physical findings from Observation with respect to Patello-femoral syndrome:
 

Observation:
• 1. Wasting of VMO (L>R) 2. Femoral anteversion (IR) and patella
squinting (L>R) 3. Prominent ITB groove 4. Over-pronated feet 5. Tilted
rotated laterally deviated patella
 Review the following findings from the physical examination:

•Swelling tests: negative

•Gait: excessive internal rotation/ over-pronation
•Reproduction of Pain: - squat reproduced anterior knee pain (L) and ® Actives: - (L) knee flexion ↑anterior knee pain -
(L) Kn extension ↑posterior pain
•Passives: - (L) Kn ext ↑, E/Abd and E/Add ↑ pain - (L) Kn F/Abd, F/Add ↑ pain
•Pat-fem glides: - hypomobile medial glide restricted by tight lateral retinaculum and possibly ITB
•- hypomobile caudad glide - with compression - ISQ Critical Angle Test: - Positive with maximal reproduction at 100°,
decreased pain with passive medial glide of patella
• 
•Muscle Length Tests
•Thomas test/ Ober’s test – tight hip flexors/ quads and ITB
•VMO/VL activation Pattern – VL activates before VMO causing lateral tracking of the patella
•Meniscal and Ligament Tests: NAD SLR: - Positive with reproduction of posterior knee pain at 65° ↑ with add/ IR
Palpation: - tender under medial and lateral surface of patella - tightness laterally, tender ITB  
•  
• Would the above presentation seem typical for Patello-Femoral syndrome or
Chondromalacia patellae? Demonstrate your Clinical Reasoning.
• What are the implications of the following muscle length and strength tests revealed on
subsequent examination?
Muscle imbalances around hip and knee (L>R):
1.Tight ITB
2. Tight rectus femoris
3. Weak gluteus medius
4. Tight hamstrings  
• Implications of Biomechanical faults found on examination:
• OA D/D
• QUESTIONS ??
• THANKS