Assessing Muscoskeletal Pain: Physical exam

Physical exam: knee checks I would perform are:

1. Bulge Sign: Applying lateral pressure to the area adjacent of the patella will be positive if fluid is present on medial knee joint, also palpating this area will allow for assessment of patellar tendinitis. (Dains, Baumann, and Scheibel, 2016)
2. McMurray Maneuver: With patient supine, maximally flex knee and hip; externally and internally rotate tibia with one hand on distal end of tibia: with other hand, palpate joint to test for meniscus injury if palpable or audible click is heard. (Dains, Baumann, and Scheibel, 2016)
3. Collateral Ligament Test: Applying medial or lateral pressure with the knee flexed 30 degrees and when it is extended. If sprained it will show laxity in movement and no solid end points. (Dains, Baumann, and Scheibel, 2016)
4. Lachman Test: With knee flexed 30 degrees, pull tibia forward with one hand while other hand stabilizes femur. A positive test is a mushy or soft end feel when tibia is moved forward, indicating damage to anterior cruciate ligament. (Dains, Baumann, and Scheibel, 2016)
5. Monitor patient gait, ability to do stairs, or kneel, monitor for flexion and extension pain to look for tibial tubercle injury related to Osgood-Schlatter disease. (Dains, Baumann, and Scheibel, 2016)

Overall look of knee color, swelling, temperature of skin to palpation, and patient vitals to monitor for fever.

Diagnostic results:

Complete Blood Count to monitor white count to look for infection. Estimated sed rate to look for inflammation. (Dains, Baumann, and Scheibel, 2016)

Radiography 4 view film of knee for an anteroposterior, lateral, tunnel, and a 30-degree sunrise view of the patella. (Dains, Baumann, and Scheibel, 2016) Radiography films would help view knee, ligaments, and bone to view for injury. May also need a knee Ultrasound. Use of magnetic resonance imaging or computed topography scan would be utilized if no answers obtained from physical exam and preliminary diagnostic tests.

A.

Differential Diagnoses:

1. Patellar Tendinitis: Jumpers knee, overuse of knee, inflammation of distal extensors of the knee joint. Excess strain on knees from jumping and running. Patient experiences dull, achy knee pain, associated with clicking or popping, can involve one or both knees. (Dains, Baumann, and Scheibel, 2016) Patellar tendinopathy is a common musculoskeletal dysfunction in athletes with 11-14% of non-elite players of basketball, volleyball, and handball per Scattone Silva, Nakagawa, Ferreira, Garcia, Santos, and Serrao (2016). They further share 53% quit sport careers due to it, as the impaired knee extensor muscles cause tendon overload and the recommendation is for strengthening of quadriceps and hamstring muscles to help distribute force equally with jumping and increasing the ankle dorsiflexion as these contribute to patellar tendinopathy
2. Meniscus Injury: A medial meniscus injury is more common than a lateral meniscus tear and is generally obtained due to twisting injuries, the patient will have problems with flexion, and bearing weight they will experience clicking and catching of the knee which can be swollen and tender. (Dains, Baumann, and Scheibel, 2016) This will generally affect one knee rather than both, especially at the same time. Mosich, Lieu, Ebramzadeh, and Beck, (2018) share 80-90% occur with athletic activity and meniscus repair seen in two studies showed a 37% mean re-tear rate within 17 months. They further share success rate reported at 80% with simple tears and arthroscopy is the surgical repair choice. They state 889% return to sports at the pre-injury level with isolated meniscus tears, and repair is better than meniscectomy due to increased risks of osteoarthritis in the long run.
3. Medial Collateral Ligament Sprain: Caused by valgus stress to the knee, the patient typically limps after the injury. Andrews, Mckean, and Ebraheim (2017) share the medial collateral ligament is one of four major ligaments that supports the knee, stabilizes the medial knee joint, protects of valgus stress, rotational forces and anterior translational forces on the tibia. They further share 40% of all knee injuries of this type are related to trauma and change in speed direction of knee activity the patient can experience the knee giving out or popping, then the joint fills with blood. They also state the patient can return to previous activity without treatment in 10-20 days, but injury is graded and if a grade 3 can recur and may require surgery as other ligaments may be involved and these recur at a rate of 23%.
4. Anterior Cruciate Ligament (ACL) Tear: Occurs if the knee is twisted or hyperextended causing stretching or tearing of ligaments, with the ACL in the center of the knee, the patient hears a pop, giving way of the knee and swelling. (Dains, Baumann, and Scheibel, 2016) The ACL is the 2nd ligamentous restraint of the knee to abduction per Bates, Nesbitt, Shearn, Myer, and Hewett (2015), the medial cruciate ligament ruptures 20-40% of the time with the ACL injury. They further share the ACL restrains 85% of the anterior force of the knee. This type of injury can take 6-12 months to heal, typically requires surgery in 75% of patients. (Bates et al., 2015) Bates et al. further shares there are negative effects within 15 years of surgery and 70% occur during non-contact sports with rapid deceleration and change in direction.
5. Osgood-Schlatter Disease: Found in adolescent males most often, patient experiences pain and swelling in the anterior part of the tibial tubercle. Strenuous activity of the quadricep muscle causes limping by the patient, and pain that worsens with kneeling or climbing stairs, the knee may be warm to touch, and tender at the tibial tubercle with increased pain on flexion and extension while having a normal knee joint. (Dains, Baumann, and Scheibel, 2016) Traction of the patellar tendon at its attachment of tibial tubercle mostly is sports related with running and jumping, the patient can use ice, non-steroidal anti-inflammatories, and exercises that strengthen the quadriceps and hamstring muscles per Indiran, and Jagannathan (2018). This is typically found in males more than females 215 are adolescent athletes compared with 4.5% non-athletes per Kalbiri, Tapley, and Tapley (2014).  They further share the injuries are related to earlier induction to sports, decreased time between sporting seasons, and performance pressure that lead to overuse. They also share patients can be tested using the single leg squat as this is difficult to do with this injury. Utilizing straight leg raises, wall squats, and rope jumping after healing can strengthen quadricep and hamstring muscles and the use of a intra patella strap can help strengthen the knee for mobility.