1. Knee examination

2. Anatomy

3. Look Feel Move: Special tests Active Passive ROM: Extension= 0 to -10°
Flexion= °

4. Special tests Sag sign Posterior/anterior drawer McMurray’s Lachman’s
Valgus/Varus stress
Patellar apprehension

5. Examine the joint above and below! Don’t forget the other knee.
Neurovascular integrity
X-ray 2 views, MRI and aspiration are the investigation options.
What investigations?

7. History Traumatic: Where is the pain? Mechanism of injury: Pyrexial?
Was there a pop?
Immediate or delayed swelling
Ability to weight bear and carry on activity
Joint instability
Pyrexial?
Occupation
Non traumatic also include:
Morning stiffness, pain after exercise.
Tick bites
Recent infections (including sexually transmitted diseases)
Hx of Gout/psoriasis
Pop suggests ligament tear or fracture

8. A 32 year old man twisted his knee while skiing
A 32 year old man twisted his knee while skiing. Although his knee was painful he managed to complete the run. By the next morning his knee was visibly swollen. On examination there was reduced range of movement in his knee and he was tender over the medial joint line.
What is the most likely diagnosis:
Medial meniscus tear
Medial collateral ligament injury
Lateral collateral ligament injury
Haemarthrosis
ACL injury

9. Meniscus injury Twisting injury
The effusion may take some time to develop.
Pain over the joint line
Medial meniscus tears are far more common than lateral due to the medial meniscus being less mobile and thinner anteriorly.
Healing may be slow especially if the deeper 2/3 are involved due to the poorer blood supply.
Mx:
Conservative= RICE
Surgical= repair or meniscectomy

10. Medial collateral ligament injury Lateral collateral ligament injury
A 22 year old male presents with a painful, swollen right knee after kicking a wall. He describes a twisting and popping feeling on impact with the wall and the knee swelled quickly.
What is the diagnosis:
Medial meniscus tear
Medial collateral ligament injury
Lateral collateral ligament injury
Haemarthrosis
ACL injury

11. Haemarthrosis

12. A 12 year old boy fell off his bike and hurt his left knee
A 12 year old boy fell off his bike and hurt his left knee. The knee promptly swelled to twice its size and was tender. This has happened on multiple occasions and his brother has had similar admissions:
Developmental hip dysplasia
Genu varus
Osgood-Schlatter disease
Perthes disease
Haemarthrosis
Still’s disease
Septic arthritis
Transient synovitis

13. A 65 year old man tripped walking along a cobbled street and landed on his right knee. On examination the right knee is swollen and painful. He can walk with help however cannot straight leg raise.
What is the most likely diagnosis?
ACL injury
PCL injury
Lateral meniscus tear
Medial meniscus tear OA
Osteochondritis dessicans
Patellar fracture RA
Tibial plateau fracture

14. A 28 year old man presented following a kick to the side of the knee while playing football. He describes his left knee being hit from the left. Since the kick he has been unable to weight bear and his knee feels unsteady. On examination his knee is tender but is not swollen.
What is the most likely diagnosis?
ACL injury
PCL injury
Lateral meniscus tear
Medial meniscus tear OA
Osteochondritis dessicans
Patellar fracture RA
MCL injury
LCL injury

15. LCL and MCL injury Valgus stress (outside of the knee)=MCL
Varus stress (inside of the knee)=LCL
Pain and knee instability
O’Donoghue’s terrible triad:
MCL
Medial meniscus
ACL

16. Housemaids knee/carpet fitters knee
A 47 year old man presents to GP with pain and swelling directly over both patellae. He has just started a part time job as a carpet layer. On examination there is no other abnormality of the knee.
What is the most likely diagnosis?
ACL injury
Bakers cyst
Chrondromalacia patellae
Medial meniscus tear OA
Prepatellar bursitis RA
Pellegrini-Stieda disease
Osteochondritis dissecans
Housemaids knee/carpet fitters knee
Infrapatellar bursitis is known as clergyman’s knee (more erect position than housemaids knee)

17. A 60 year old lady has a 12 month history of worsening pain and swelling in her left knee for which she has been taking NSAIDs and paracetamol. On examination there is crepitus in the left knee and pain limits knee movement. A significant valgus deformity can be seen on standing.
What is the most likely diagnosis?
ACL injury
Bakers cyst
Chrondromalacia patellae
Medial meniscus tear OA
Prepatellar bursitis RA
Pellegrini-Stieda disease
Osteochondritis dissecans

18. OA 4 radiological findings: Osteophytes Joint space narrowing
Bone cysts
Subarticular sclerosis

19. A 14 year old boy presents with pain in his right knee that is worse when he plays football. On examination he is apyrexial but the right tibial tuberosity is enlarged and painful.
What is the likely diagnosis?
Developmental hip dysplasia
Genu varus
Osgood-Schlatter disease
Perthes disease
Haemarthrosis
Still’s disease
Septic arthritis
Transient synovitis

20. Osgood-Schlatters Disease
Osteochondritis of the tibial tuberosity where the patellar tendon attaches.
Most common in active boys
Pain and swelling around the tuberosity
Worse with exercise particularly leg extension.
Mx= rest and analgesia

21. A 64 year old man has a painful swollen right knee
A 64 year old man has a painful swollen right knee. Symptoms began 2 days previous. There is no history of trauma. Joint aspirate shows pus cells, negatively birefringent crystals and no organisms.
What is the most likely diagnosis?
Reactive arthritis
Pseudogout
ACL injury
Gout
Rheumatoid arthritis

22. Gout Vs Pseudogout Acute inflammatory mono-arthritis
Red, hot, swollen joint- aspirate to rule out septic joint
NSAIDS then colchicine in an acute attack
Allopurinol may be needed to prevent further attacks if >2 per year
Gout
Pseudogout
Middle aged men
Elderly women
Metatarsophalangeal joint classically
Knees
Negatively birefringent fine needle shaped crystals
Positively birefringent brick/rhomboidal shaped crystals

23. A 65 year old lady presents with difficulty walking on her right leg because of pain. She has a history of a right knee replacement. On examination she is pyrexial and her right knee is hot, swollen and tender.
What is the most likely diagnosis?
ACL injury
Bakers cyst
Chrondromalacia patellae
Medial meniscus tear OA
Prepatellar bursitis RA
Septic arthritis
Pellegrini-Stieda disease
Osteochondritis dissecans

24. Bakers cyst
RA!!
What is this?
What diseases are associated?

25. A 33-year-old cab driver was involved in a rear-end motor vehicle crash and hit his knee against the dashboard. He presents with a six-week history of knee pain, and difficulty walking down inclines.
What is the most likely diagnosis?
ACL injury
PCL injury
Lateral meniscus tear
Medial meniscus tear OA
Osteochondritis dessicans
Patellar fracture RA
MCL injury
LCL injury

26. PCL tears Rare in isolation
Substantial knee trauma caused by forcibly pushing the tibia back.
Goalkeepers and RTAs after hitting the dashboard.
Difficulty walking up and down stairs/inclines
Less swelling and instability than ACL.
Can be treated with rehab alone.

27. A 17-year-old football player sustained a noncontact knee injury while her leg was planted to make a turn. She heard a pop and felt her knee buckle.
What is the most sensitive clinical test to establish the diagnosis?
Posterior drawer
McMurray
Lachman
Anterior drawer

28. ACL tears
ACL injury typically results from rotational stress on a planted/fixed weight baring joint.
POP
Immediate haemarthrosis
Joint instability

29. A 30-year-old man presents with lower back, knee, and ankle pain of two months’ duration. He also has had burning on urination. Physical examination reveals a rash over the palms and soles. Sacroiliitis is present on radiographs.
The clinical diagnosis is:
ankylosing spondylitis
psoriatic arthropathy
gonococcal arthritis
reactive arthritis (Reiter’s disease)

30. Reiter’s syndrome A reactive arthritis (Seronegative arthropathy)
Triad of conjuctivitis, urethritis and arthritis
Can’t see, Can’t pee, Can’t climb a tree
Often precipitated by genitourinary or gastrointestinal infections. The most common triggers are intestinal infections (Salmonella, Shigella or Campylobacter) and sexually transmitted infections (Chlamydia trachomatis)
1-2 months after the onset of arthritis, some develop keratoderma blennorrhagicum.

31. Weird and wonderful
Pellegrini-Stieda disease- ossification of the superior part of the medial collateral ligament of the knee.
Osteochondritis dissecans- causes pain and swelling of the affected joint which catches and locks during movement.
Chrondromalacia patellae- inflammation of the underside of the patella and softening of the cartilage. Pain going up and down stairs from rubbing against femur.
Ehlers-Danlos syndrome, Marfan’s and other connective tissue disease.