Knee PEx Special Tests
MCL	Valgus stress test: Stabilize lateral thigh; apply abduction force to lower leg Laxity indicates MCL injury
ACL	Anterior drawer test • Patient supine with knee flexed • Grip proximal tibia with both hands & pull anteriorly Lachman test • Place knee at 30 degrees flexion • Stabilize distal femur with 1 hand & pull proximal tibia anteriorly with the other Laxity of tibia indicates ACL injury
Meniscus	Thessaly test • Patient stands on 1 leg with knee flexed 20 degrees • Patient then internally & externally rotates on flexed knee McMurray test • Passive knee flexion & extension while holding the knee in internal or external rotation

	Patellar Dislocation
RFs	·       Joint laxity ·       Misaligned lower extremity ·       Tight iliotibial band ·       Patellar subluxation ·       Competitive sports, dance, military training
S/S	How injury happens? ·       Quick, twisting motion around a flexed knee ·       Feeling of knee giving way, severe pain, popping noise Examination: ·       lateral dislocation of patella, ·       ⤵️ extension

	Patellar Dislocation
RFs	·       Joint laxity ·       Misaligned lower extremity ·       Tight iliotibial band ·       Patellar subluxation ·       Competitive sports, dance, military training
S/S	·       Quick, twisting motion around a flexed knee ·       Feeling of knee giving way, severe pain, popping noise ·       Examination: lateral dislocation of patella, ⤵️  extension

Pes anserinus pain syndrome / anserine bursitis

Cause: gait, overuse, or trauma. RF: obesity, DM, knee OA, and angular deformity of the knee. Clx: ·       Pts experience localized pain over the anteromedial tibia, ·       Examination shows localized tenderness over the medial tibial condyle just below the joint line; ·       No swelling, erythema, and induration. Dx: Clx Tx: Quadriceps strengthening exercises + NSAIDs

	Popliteal (Baker) cyst
Causes	Extrusion of fluid from knee joint space into semimembranosus/gastrocnemius bursa
RFs	·       Trauma (Meniscal tear) ·       Underlying joint disease (Osteoarthritis, rheumatoid arthritis)
Clx	·       Asx bulge behind knee that diminishes with flexion ·       Posterior knee pain, swelling, stiffness
Comp	·       Venous compression (leg/ankle swelling) ·       Dissection into calf (erythema, edema, positive Homan sign) ·       Cyst rupture (acute calf pain, warmth, erythema, ecchymosis)

	Running Injuries in foot & ankle
Stress fx	·       Insidious ·       Focal pain in navicular or metatarsals ·       RF: sudden ⤴️ in intensity of training, poor running mechanics, 👩🏻 w/ anorexia nervosa
Plantar fasciitis	·        Plantar surface of the heel ·       Worse when initiating running ·       Worse at first step of the day
Achilles tendinopathy	Buming pain or stiffness 2-6 cm above the posterior calcaneus
Morton neuroma	·       Numbness or pain between the 3rd & 4th toes ·       Clicking sensation when palpating space between 3rd & 4th toes while squeezing the metatarsal joints
Tarsal tunnel syndrome	·       Compression of the tibial nerve at the ankle ·       Buming, numbness & aching of the distal plantar surface of the foot/toes

Achilles tendinopathy ·       exercise-induced heel pain, ·       tenderness are prominent at the posterior heel, ·       palpable thickening of the tendon. ·       pain is reproduced by passive dorsiflexion of the ankle (which stretches the Achilles tendon) Calcaneal stress fractures ·       inexperienced athletes after initiation of a high-impact exercise. ·       Like plantar fasciitis, they cause pain at the heel that is worse with weight bearing. ·       pain is elicited by firm palpation at the sides of the heel Charcot joint (neurogenic arthropathy) ·       Poorly controlled DM, ·       deformity of the foot and significant sensory deficits. ·       Disorder relates to recurrent trauma due to loss of proprioception and pain sensation, ·       The associated pain is typically mild. Tarsal tunnel syndrome ·       Caused by compression of the tibial nerve where it passes under the flexor retinaculum at the medial aspect of the ankle. ·       presents w/ numbness and paresthesia at the toes and distal sole. ·       The pain is nocturnal and is provoked by percussion at the tarsal tunnel (not stretching of the plantar fascia, as seen in this patient).

	Heel Pain
Plantar fasciitis	·       Pain maximum upon first stepping out of bed ·       Local point tenderness with dorsiflexion of the toes
Ruptured plantar Fascia	·       Sudden-onset pain ·       Loss of height of the arch ·       Visible swelling or ecchymosis
Bone infection/metastasis	·       Constant throbbing pain ·       Nocturnal worsening
Calcaneal stress fracture	·       Worse with activity ·       Palpation of the bone elicits tenderness (squeeze test)
Tarsal tunnel syndrome	·       Pain, paresthesia & numbness on the sole of the foot ·       Percussion tenderness over the posterior tibial nerve in the tarsal tunnel

	Stress fx
RFs	·       Repetitive activities (Running, gymnastics) ·       Abrupt ⤴️ in physical activity ·       Inadequate calcium & vitamin D ·       Female athlete ∆👩🏻: ·       low caloric intake, ·       hypomenorrhea/amenorrhea, ·       low bone density
Clx	·       Point tenderness at fx site ·       May have ⊖ x-ray in first 6 weeks
Tx	·       Reduced weight bearing for 4-6 ws ·       Referral to orthopedic surgeon for fracture at high risk for malunion (anterior tibial cortex, 5th metatarsal)

	Plantar Fasciitis
RF	·       Pes Planus (flat foot) ·       Obesity ·       Working or exercising on hard surfaces
S/S	·       Pain at plantar aspect of heel & hindfoot ·       Worse with weight bearing (especially after prolonged rest)
Dx	·       Tenderness at insertion of plantar fascia ·       Pain with dorsiflexion of toes ·       Presence of heel spurs on x-ray has low sensitivity & specificity
Tx	·       Activity modification ·       Stretching exercises ·       Heel pads/orthotics

Morton Neuroma

What is it? mechanical induced neuropathy Sx: degeneration of nerves b/w digits Presents w/ numbness b/w 3rd-4th toes. Pain ⊕ when u palpate 3rd-4th toes It does not cause significant deformity, and gross inspection of the foot is typically normal.

	Cord compression	Epidural abscess	Cauda equina	Ankylosing spondylitis	Disk herniation
Hx	History of cancer	Fever, high ESR	Bowel and bladder incontinence, erectile dysfunction	Under age 40, pain worsens with rest and improves with activity	Pain/numbness of medial calf or foot
PEx	Vertebral tenderness, sensory level, hyperreflexia	Same as cord compression	Bilateral leg weakness, saddle area anesthesia	Decreased chest mobility	Loss of knee and ankle reflexes, positive straight leg raise
X-ray	may be ⊖	may be ⊖	ⓝ	Bomboo sign
Dx	MRI	·       ⊕ inflammatory markers + fever ·       ⊕ MRI	MRI Confirms	Clx / Abs /
Tx	1˚ STEROIDs then go to surgery	Abx + drainage	Surgery		·       NSAIDs / Acetaminophen

	Causes	Clx
MSK	Mechanical (muscle strain, spasm, degenerative arthritis)	·       ⓝ neurologic examination ·       ⊖ straight leg raise ·       paraspinal tendemess
	Herniated nucleus pulposus/ disk disease	·       Radiculopathy (usually L4-L5) ·       ⊕straight leg raise ·       ⊕ neurologic signs
	Spinal stenosis	·       Pseudoclaudication ·       Better with spine flexion ·       Worse With extension ·       Older age
	Cornpression fx	·       Older age ·       More cornmm in wornen ·       Trauma/fall (may be minor)
Inflammatory	·       Ankylosing spondylitis ·       reactive afiritis, ·       psoriatic arthritis, ·       inflammatory bowel disease	·       Better with activity or exercise ·       No improvement with rest ·       Gradual onset ·       HLA-B27 present
Metastatic	Cancer metastasis to bones	·       PMHx of malignancy ·       Worse at night ·       Unintentional weight loss ·       Cauda equina syndrome (weakness, urine retention/incontinence, saddle anesthesia)
Infectious	Osteomyelitis	·       Fever, ·       Severe pain at a specific point ·       IVDU ·       Recent infection

	Causes of chronic low back pain
Mechanical (muscle strain, disc degeneration)	·       Normal neurologic ·       Paraspinal tendemess
Radiculopathy (herniated disk)	·       Pain radiates below knee ·       ⊕ straight-leg raise
Spinal stenosis	·        Pseudoclaudication ·       Pt reports relief of pain when leaning forward
Inflammatory (spondyloarthropathy)	Worse with rest, better with activity
Metastatic cancer	·       Worse at night ·       Not relieved w/ rest
Infectious (osteomyelitis)	·       Recent infection or IVDU ·       Fever. focal spine tenderness

	Acute Lumbosacral Radiculopathy (Sciatica)
Features	Herniated disk
S/S	Lower back pain, ⊕ raise leg test
Dx	·        Clx → Start tx based on it ·       MRI Confirms dx (would not change initial tx) ·       Indications for MRI: ·       Progressive sensory or motor deficits, ·       Signs of cauda equina syndrome (eg, saddle anesthesia), ·       Concern for epidural abscess (eg, fever, intravenous drug abuse).
Tx	·       Most pts  will experience spontaneous resolution; focus on tx of sx ·       1st-line: NSAIDs / Acetaminophen ·       Activity modification is often advisable, but patients should be encouraged to maintain moderate physical activity.

	Indications for imaging in low back pain
X-ray	·       Osteoporosis ·       Compression Fx ·       Suspected malignancy ·       Ankylosing spondylitis
MRI	·       Sensory/motor deficits ·       Cauda equina syndrome (eg, urine retention, saddle anesthesia) ·       Suspected epidural abscess/infection (fever, intravenous drug abuse, concurrent infection, hemodialysis)
Radionuclide bone scan / CT scan	= MRI but pt can’t have MRI

	Tx of Low back pain
Acute	·       Maintain moderate activity ·       NSAlDs or acetaminophen
Chronic	Exercise therapy (stretching/strengthening, aerobic)
2˚ Prevention	Exercise therapy Education

	Notes	PEx	X-ray
Adhesive capsulitis	·      fibrosis leading to ⤵️  distensibility ·      common in middle-aged or elderly ·      common w/ rotator cuff tear + proximal humeral fx	⤵️ Active & passive ROM Stiffness + pain	ⓝ
Rotator cuff impengment	Follow an inury (FOOSH)	·      ⓝ Passive ROM ·      ⤵️ Abduction + External Rotation ·      Subacromial pain ·      ⊕ Impengment tests (Neer + Hawkins)	ⓝ
Rotator cuff tear	FOOSH Age > 40 ys	·      Weakness (rather than just pain) ·      ⓝ passive ROM ·      ⊖ Impengment tests (Neer + Hawkins)	ⓝ
Rotator cuff tendinitis	·       Overuse ·       Supraspinatus	=	ⓝ
Biceps tendinopathy	·       Anterior shoulder Pain	⤵️ Flexion (biceps) especially w/ carrying stuff, overhead reaching	ⓝ
Glenohumeral OA	·       Caused by trauma ·       Anterior / deep shoulder pain	⤵️ ACTIVE + PASSIVE ABDUCTION + EXTERNAL ROTATION	🆎 (OA findings)
Calcific Tendinopathy	Hydroxyapatite deposits on rotator cuff	·      ⓝ Passive ROM ·      PAINFUL abduction	calcifications

Rotator cuff tendinopathy & tear
Rotator cuff impingement or tendinopathy	·       Pain with abduction, external rotation ·       Subacromial tenderness ·       ⓝ ROM with ⊕ impingement tests (Neer, Hawkins)
Rotator cuff tear (انقطع)	·       FOOSH/Hx of TRAUMA ·       Similar to rotator cuff tendinopathy ·       Weakness with abduction & external rotation ·       NORMAL PASSIVE ROM ·       Age >40

Lateral epicondylitis
Clx	• Subacute to chronic lateral elbow pain • History of repetitive or forceful wrist extension • Peak incidence age 45-54
Dx	• Tenderness at epicondyle & proximal extensor muscles • Pain with resisted wrist extension or supination • Pain with passive wrist flexion
Tx	• Modified activity & ergonomics • Inelastic counterforce brace • Nonsteroidal anti-inflammatory drugs (topical or oral) • Stretching & progressive resistance exercise • Physical therapy

	De quivern tenosynovitis
features	Inflammatio of 1st extensor compartement
S/S	+ fenkelstein (make fist –> pain)
Dx	Clx
Tx	·       NSAIDS ·       Forearm-based thumb spica splint

	Complex regional pain syndrome
Trigger	Trauma: fracture, sprain Surgery
S/S	·       Pain: severe, regional (not dermatomal), burning/stinging ·       Edema, abnormal sweating (non-pitting) ·       Vasomotor changes, altered skin temperature ·       Trophic skin, hair & nail changes
Dx	·       Primarily clinical ·       X-ray: patchy demineralization ✳️ ·       Bone Scan: ⤴️ uptake in affected limb
Tx	·       Physical & occupational therapy, ·       Exercise ·       💊 NSAlDs / Antineuropathic medications (eg, pregabalin, TCAs)

	Supracondylar Fx
Clx	FOOSH – Pain, swelling, limited ROM
Dx	X-ray: occult fx (خفي): Posterior fat pad (usually absent), fx line, or displacement of humerus
Tx	Nondisplaced: long arm splint & sling Displaced: surgical reduction & pinning
Comp	Neurovascular injury ·       Brachial a: diminished distal pulse ·       Median n: TRANSIENT motor/sensory loss Compartment syndrome ·       ⤴️ Swelling + Pain unresponsive to analgesics ·       4 Ps (Pulseless, Pale, Parasthesia, Paralysis) ·       1˚: Remove Bandages ·       2˚: Measure compartment pressure ·       3˚ Fasciotomy Emergently