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Knee Exam

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181. Popliteal cyst

into the development of popliteal cysts. Br J Surg. 2004;91:1313-1318. http://www.ncbi.nlm.nih.gov/pubmed/15376180?tool=bestpractice.com The most common underlying conditions that lead to overproduction of synovial fluid include arthritis and meniscal tears. [Figure caption and citation for the preceding image starts]: Popliteal cyst Created by BMJ Publishing Group [Citation ends]. History and exam presence of risk factors popliteal bulge knee pain leg swelling calf tenderness calf ecchymosis lyme disease knee (...) Popliteal cyst Popliteal cyst - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Popliteal cyst Last reviewed: February 2019 Last updated: March 2018 Summary Common accumulation of synovial fluid that is usually the result of a knee joint abnormality, such as arthritis or a cartilage tear. May present with swelling or pain behind the knee, but most cases are asymptomatic. May rupture, leading to severe pain and calf

2018 BMJ Best Practice

182. Adhesive capsulitis

of motion. Rookmoneea M, Dennis L, Brealey S, et al. The effectiveness of interventions in the management of patients with primary frozen shoulder. J Bone Joint Surg Br. 2010;92:1267-1272. http://www.ncbi.nlm.nih.gov/pubmed/20798446?tool=bestpractice.com History and exam shoulder stiffness decreased shoulder active range of motion decreased shoulder passive range of motion positive coracoid pain test positive shoulder shrug test presence of risk factors shoulder pain alternative diagnosis not suggested (...) shoulder instability) negative relocation test (to further exclude anterior shoulder instability) negative Kim test (to exclude posteroinferior labral lesion of the shoulder) age 40 to 70 years diabetes mellitus prior hx of adhesive capsulitis shoulder pain and immobilisation previous shoulder surgery female sex thyroid disease Diagnostic investigations plain film radiographs MRI/MR arthrogram shoulder CT arthrogram Treatment algorithm ACUTE Contributors Authors Complex Shoulder Knee and Sports Surgery

2018 BMJ Best Practice

183. Secondary hyperparathyroidism

://www.sciencedirect.com/science/article/pii/S0085253815514154 http://www.ncbi.nlm.nih.gov/pubmed/16641930?tool=bestpractice.com History and exam presence of risk factors features of chronic renal failure features of underlying malabsorption syndrome muscle cramps and bone pain perioral tingling or paresthaesia in fingers or toes Chvostek's sign Trousseau's sign bowed legs or knock knees fractures ageing chronic renal failure vitamin D deficiency: inadequate sunlight exposure nutritional deficiency (especially absence

2018 BMJ Best Practice

184. Patellofemoral pain syndrome

Patellofemoral pain syndrome Patellofemoral pain syndrome - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Patellofemoral pain syndrome Last reviewed: February 2019 Last updated: March 2018 Summary Patellofemoral pain syndrome is one of the most common disorders of the knee, accounting for 25% of knee injuries seen in a sports medicine clinic. The causes of patellofemoral problems are multifactorial, including (...) abnormal patellofemoral joint mechanics, lower kinetic chain alterations, and overuse. Patients typically note the insidious onset of an ill-defined ache localised to the anterior knee behind the patella. There is no one physical examination or imaging test that is a standard for diagnosis. Treatment is focused on activity modification and correction of specific risk factors. Non-operative treatment is successful in the majority of cases. Definition Patellofemoral pain syndrome is defined as knee pain

2018 BMJ Best Practice

185. Meniscal tear

present. [Figure caption and citation for the preceding image starts]: Anatomical structures around the menisci Created by BMJ Publishing Group [Citation ends]. History and exam presence of risk factors knee swelling sensation of knee instability or buckling/catching knee pain tenderness at joint line and joint line crepitation positive McMurray's test positive Apley's test positive hyperextension test popliteal (Baker's) cyst in chronic cases limited range of motion acute trauma (twisting injury (...) of the knee, knee pain, or any combination of these symptoms. MRI scan considered most accurate and non-invasive method of diagnosis. Meniscal tears are mainly either traumatic or degenerative. Most tears do not heal spontaneously and are treated arthroscopically by meniscus repair (if torn in a clear, clean pattern) or partial meniscectomy (if torn in a complex or degenerative pattern). Successful outcome requires close follow-up and adherence to physiotherapy. Definition The medial and lateral menisci

2018 BMJ Best Practice

186. Musculoskeletal lower back pain

://annals.org/article.aspx?articleid=736814 http://www.ncbi.nlm.nih.gov/pubmed/17909209?tool=bestpractice.com History and exam obesity, stress, and psychiatric comorbidities history of prior lower back pain history of prior treatment pain radiation does not extend beyond the knee absence of red-flag symptoms absence of fever, fluctuance, exquisite tenderness to palpation sensory, motor, and deep-tendon reflex examinations within normal limits negative straight- or crossed straight-leg raise test dull

2018 BMJ Best Practice

187. Legg-Calvé-Perthes' disease

and is more commonly seen in boys. The cause is hypothesised to be single or multiple vascular events, followed by re-vascularisation. In later life, it can lead to a painful and poorly functioning hip. The disease was first described independently by Jacques Calvé, Arthur T. Legg, and Georg Perthes in 1910. History and exam presence of risk factors limp limited range of motion at the hip joint short stature muscle wasting hyperactivity Trendelenburg's sign synovitis knee pain thigh pain groin/buttock (...) , though bilateral involvement is present in 10% of cases. Clinical features include a limping gait and hip pain frequently radiating into the thigh, knees, groin, or buttocks. Pain is worse with activities. Treatment is age-dependent. Options include mobilisation and monitoring, non-surgical or surgical containment, or salvage procedures. Definition A self-limiting disease of the femoral head comprising of necrosis, collapse, repair, and re-modelling that presents in the first decade of life

2018 BMJ Best Practice

188. Torsion of the lower limb in children

of the bones (i.e., version), capsular laxity or tightness, and muscular control during growth. Staheli LT. Rotational problems in children.Instr Course Lect. 1994;43:199-209. http://www.ncbi.nlm.nih.gov/pubmed/9097150?tool=bestpractice.com History and exam convex lateral border of the sole of the foot asymmetric hip range of motion foot progression angle >2 standard deviations outside the mean for age hip medial rotation >2 standard deviations outside the mean for age hip lateral rotation >2 standard (...) deviations outside the mean for age thigh-foot axis >2 standard deviations outside the mean for age transmalleolar axis >2 standard deviations outside the mean for age heel-bisector line sitting in the W position medial-facing patella (squinting or cross-eyed patella) lateral knee thrust neuromuscular disease FHx of rotational problems female sex intrauterine position abnormalities short stature or disproportionate body-limb ratio ligamentous laxity Diagnostic investigations anteroposterior pelvic x-rays

2018 BMJ Best Practice

189. Slipped capital femoral epiphysis

Klein line will intersect the epiphysis. An abnormal Klein line does not intersect the epiphysis, as the femoral neck has moved proximally and anteriorly relative to the epiphysis Image courtesy of John M. Flynn, MD [Citation ends]. History and exam presence of risk factors weight (>90th percentile) gait with affected leg externally rotated groin or knee pain bilateral hip pain Trendelenburg's gait restricted range of motion weight (<50th percentile) symptoms of hypothyroidism or panhypopituitarism

2018 BMJ Best Practice

190. Periodic limb movement disorder

of sleep-wake disturbance must be excluded. The PLMS-I is used to determine the frequency of periodic limb movements of sleep (PLMS) and is calculated as the number of PLMS per total hours of sleep time. PLMS are repetitive limb movements (mostly of the legs), occurring mainly during non-rapid eye movement (non-REM) sleep; they are characterised by dorsiflexion of the toes and ankles and occasionally flexion of the hip and knee. PLMS may arise in normal individuals, and their clinical significance (...) and excessive daytime sleepiness is controversial, however, and the aetiology is unclear. History and exam poor sleep daytime somnolence and fatigue periodic limb movements (mostly legs) age >70 years female gender re-enactment of dreams during the night irresistible urge to move legs, and abnormal sensations in lower limbs snoring early-morning dry mouth headache elevated body mass index withdrawal from benzodiazepines or barbiturates hx of neuroleptic medication hx of dopaminergic medication pallor iron

2018 BMJ Best Practice

191. Spina bifida and neural tube defects

ends]. History and exam maternal risk factors for child with spina bifida hx of elevated triple or quadruple screening test during antenatal assessment hx of abnormality on antenatal ultrasound open spina bifida lesion: myelomeningocele, myeloschisis, meningocele closed spina bifida lesion: asymmetrical gluteal fold or dimple, haemangioma, hairy patch, or other cutaneous markings bulging fontanelle rapid head growth abnormal urinary voiding leakage of meconium or stool mid-line congenital anomalies (...) deformity hip and knee flexion contractures feeding difficulties congenital scoliosis congenital kyphosis inadequate maternal folate intake previous pregnancy affected by, or personal hx of, spina bifida or other neural tube defect FHx of spina bifida or other neural tube defect Hispanic ancestry or ethnicity trisomy 18 or trisomy 13 antenatal exposure to valproic acid, carbamazepine, isotretinoin, or methotrexate inadequate maternal vitamin B12 intake maternal obesity maternal diabetes female sex

2018 BMJ Best Practice

192. Bursitis

movement of adjacent structures. Over 150 bursae are located throughout the human body. Some are superficial and more vulnerable; others are deeper and better protected. In primary care, bursitis most commonly presents in the knee, subacromial (subdeltoid), trochanteric, retrocalcaneal, and olecranon bursae. History and exam pain at site of bursa tenderness to palpation at site of bursa decreased active range of motion presence of risk factors low-grade temperature (septic bursitis) swelling erythema (...) rheumatoid arthritis gout or pseudogout penetrating injury osteoarthritis of the hip infection in a nearby joint lower limb length discrepancy iliotibial band contracture lumbar spondylosis valgus knee deformity low-riding shoes anatomical or functional impingement within the coracoacromial arch Diagnostic investigations clinical diagnosis Gram stain and culture of fluid aspirate crystal analysis x-ray of affected region MRI Treatment algorithm ACUTE Contributors Authors Centre Lead and Professor

2018 BMJ Best Practice

193. Limited cutaneous systemic sclerosis

Limited cutaneous systemic sclerosis Limited cutaneous systemic sclerosis - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Limited cutaneous systemic sclerosis Last reviewed: February 2019 Last updated: November 2018 Summary A type of systemic sclerosis characterised by skin fibrosis of the fingers (sclerodactyly) and, in some cases, of the face and neck or the skin distal to the elbows and/or knees. It does (...) ://www.ncbi.nlm.nih.gov/pubmed/3361530?tool=bestpractice.com lcSSc is characterised by skin fibrosis of the fingers (sclerodactyly) and, in some cases, of the face and neck or the skin distal to the elbows and/or knees. It does not affect the upper arms, upper legs, or trunk. In contrast, dcSSc also affects the trunk and the skin distal and proximal to the elbows and/or knees. The presence of anti-centromere antibodies is uncommon in patients with dcSSc; however, anti-topoisomerase I and anti-RNA polymerase III

2018 BMJ Best Practice

194. Osteochondritis dissecans

of both juvenile and adult osteochondritis dissecans remains unclear. Robertson W, Kelly BT, Green DW. Osteochondritis dissecans of the knee in children. Curr Opin Pediatr. 2003 Feb;15(1):38-44. http://www.ncbi.nlm.nih.gov/pubmed/12544270?tool=bestpractice.com History and exam presence of risk factors pain is exacerbated by activity location of pain anteromedial aspect of the knee with the knee flexed to 90 degrees location of pain lateral aspect of elbow location of pain posteromedial aspect (...) Osteochondritis dissecans Osteochondritis dissecans - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Osteochondritis dissecans Last reviewed: February 2019 Last updated: November 2018 Summary Majority of patients are adolescent or young adult athletes. Main joints involved include the knee, ankle, and radiocapitellar joint of the elbow. Bilateral in up to 25%. Variable presentation: traumatic or atraumatic, insidious

2018 BMJ Best Practice

195. Thoracic outlet syndrome

Staff Meet Mayo Clin. 1956;31:281-287. http://www.ncbi.nlm.nih.gov/pubmed/13323047?tool=bestpractice.com Urschel HC Jr. Anatomy of the thoracic outlet. In: Ferguson MK, Deslauriers J, eds. Thoracic surgery clinics, vol 17, no 4. Philadelphia, PA: Elsevier; 2007:511-520. Wilbourn AJ. Thoracic outlet syndromes. Neurol Clin. 1999;17:477-497. http://www.ncbi.nlm.nih.gov/pubmed/10393750?tool=bestpractice.com History and exam hx of repetitive jobs or overhead hobbies/activities pain in upper extremity (...) ownership in Wright Medical Inc. Dr Chaney Stewman, Dr Peter C. Vitanzo, Dr Marc I. Harwood, and Dr Pedro K. Beredjiklian would like to gratefully acknowledge Dr Harold C. Urschel Jr, Rachel Montano, and Brenda Knee, previous contributors to this monograph. HCU is an author of several references cited in this monograph. RM and BK declare that they have no competing interests. Peer reviewers Professor of Vascular Surgery St. George's NHS Healthcare Trust London UK Disclosures IL declares that he has

2018 BMJ Best Practice

196. Anterior cruciate ligament injury

://www.ncbi.nlm.nih.gov/pubmed/7358757?tool=bestpractice.com History and exam presence of risk factors audible pop rapid knee swelling inability to return to activity sensation of knee instability or buckling pain positive Lachman's test positive pivot shift manoeuvre tenderness at lateral femoral condyle, lateral tibial plateau positive anterior drawer test acute trauma female sex (after puberty) poor technique for landings history of previous ACL injury aggressive athlete with higher skill level use of cleats (...) injury, forceful hyperextension, or excessive rotational forces about the knee. Boden BP, Dean GS, Feagin JA, et al. Mechanisms of anterior cruciate ligament injury. Orthopedics. 2000;23:573-578. http://www.ncbi.nlm.nih.gov/pubmed/10875418?tool=bestpractice.com Ettlinger CF, Johnson RJ, Shealy JE. A method to help reduce the risk of serious knee sprains incurred in alpine skiing. Am J Sports Med. 1995;23:531-537. http://www.ncbi.nlm.nih.gov/pubmed/8526266?tool=bestpractice.com The ligament may

2018 BMJ Best Practice

197. Iliotibial band syndrome

Iliotibial band syndrome Iliotibial band syndrome - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Iliotibial band syndrome Last reviewed: February 2019 Last updated: August 2018 Summary Iliotibial band syndrome is the most common cause of lateral knee pain in runners. Runners predisposed to this injury are typically in a phase of over-training and often have underlying weakness of the hip abductor muscle. Male (...) runners may exhibit kinematic faults such as increased hip internal rotation and knee varus, and weakness in the external rotator muscles of the hip. Female runners may exhibit increased hip adduction and knee internal rotation, and abnormal iliotibial band strain and strain rate. In the acute phase, treatment includes activity modification, ice, non-steroidal anti-inflammatory drugs, and corticosteroid injection in cases of severe pain or swelling. During the sub-acute phase, emphasis

2018 BMJ Best Practice

198. Joint dislocation

may become dislocated, common sites include the shoulder, finger, patella, elbow, and hip. History and exam presence of risk factors characteristic posturing of joint pain inability to move joint tenderness swelling normal neurological function of shoulder and elbow sciatic nerve injury with hip dislocation injury to the femoral artery, vein, or nerve with hip dislocation concomitant injury with hip dislocation cruciate ligament injury with patellar dislocation meniscal tears with patellar (...) dislocation ligamentous injuries of the knee with patellar dislocation patellar or quadriceps tendon rupture with patellar dislocation ecchymosis with finger dislocation haemarthrosis with patellar dislocation sports-related activities motor vehicle accident ligamentous laxity Ehlers-Danlos syndrome males between adolescence and 40 years of age women aged 61 to 80 years prior history of joint instability skeletal or muscular dysplasia high Q angle external tibial torsion patella alta Diagnostic

2018 BMJ Best Practice

199. Tendinopathy

tendon in the knee, and Achilles' tendon in the heel. In athletes, common locations for tendinopathy include the Achilles' and patella tendons. In the general population, the Achilles' and lateral epicondyle are the most commonly affected. There are many terms used to characterise chronic tendon disorders. Tendonitis refers to a painful tendon with histological signs of inflammation within the tendon. Tendinosis is a localised intrinsic degeneration of unknown aetiology, characterised by localised (...) /pubmed/9848596?tool=bestpractice.com Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol. 2007 Apr;21(2):295-316. http://www.ncbi.nlm.nih.gov/pubmed/17512484?tool=bestpractice.com Khan KM, Cook JL, Kannus P, et al. Time to abandon the "tendonitis" myth. BMJ. 2002 Mar 16;324(7338):626-7. http://www.ncbi.nlm.nih.gov/pubmed/11895810?tool=bestpractice.com History and exam presence of risk factors insidious onset well-localised tenderness pain during

2018 BMJ Best Practice

200. Groin pain

. History and exam presence of risk factors acute pain related to trauma hx of sports-related or overuse injury positive anterior impingement test (FADIR test) pain on adduction against resistance (neutral hip flexion) pain on palpation of adductor tendons pain on palpation of iliopsoas pain on passive range-of-motion testing of the hip joint snapping/clicking hip positive Trendelenburg's test positive apprehension test positive modified Thomas' test pain on palpation of inguinal canal pain on palpation (...) Juan M Raposo, the previous contributors to this monograph. CJO and JMR declare that they have no competing interests. Peer reviewers Specialist in Arthroscopy of the Shoulder, Hip, and Knee; Traditional and Reverse Shoulder Replacement; and Sports Medicine Southern California Orthopedic Institute Van Nuys CA Disclosures CG declares that he has no competing interests. Use of this content is subject to our Services Legal © BMJ Publishing Group 2018 ISSN 2515-9615 Help us improve Thank you × Your

2018 BMJ Best Practice

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