Case #1
Theodore, a 26-year-old male, was referred by his primary care physician to
your office for evaluation of lateral left knee pain. He is an avid trail runner and skier
who has been complaining of a burning pain that is worsened by physical activity,
especially running and cross country skiing. He also reports increased lateral knee pain
when ascending or descending stairs that is occasionally accompanied by an audible
popping noise in the joint. He is concerned because the pain affects his daily activities
and his outdoor lifestyle.
Your initial diagnosis is IT band friction syndrome. What is the root cause of IT
band friction syndrome and which intra/extra-articular structures are most often
involved?
A. Overuse injuries; IT band, retropatellar fat pad, and the lateral femoral
epicondyle
B. Acute injuries; IT band and the greater trochanter of the femur
C. Infection; periosteum of the distal femur
D. Traumatic injury; medial femoral condyle and sartorius
Case #2
Angela, a 34-year-old female, was referred by her primary care physician to your office
for evaluation of instability of her right knee. She is a high school soccer coach who
describes “hyperextending” her knee while practicing with the team. On physical exam
you elicit a firm endpoint on anterior and posterior drawer testing, but when the knee
is flexed to 20° there is increased gapping at the lateral joint line (right knee compared
to left knee) when a varus force is applied. There is no loss of sensation and dorsiflexion
strength is 5/5 bilaterally. Her knee motion is symmetrical and her heel height
distances are 2 cm bilaterally.
Based on the physical exam findings, what structures would you expect to have been
injured?
A. Fibular collateral ligament (FCL)
D. Popliteus tendon
B. Anterior cruciate ligament
E. Popliteofibular ligament
C. Common peroneal nerve
Case #3
Martin, a 17-year-old male, was referred by his primary care physician to your
office for evaluation of numbness and weakness in his left foot. He is a high school
soccer player who was kicked in the knee during a game the night before. On physical
exam you discover a tender bruise over the lateral knee and fibular head with slight
swelling, no disruption of the skin and no loss of knee range of motion. Further
examination reveals decreased sensation over the dorsum of the foot and a foot drop.
What structure has likely been injured?
A. Fibular collateral ligament
B. Lateral meniscus
C. Common peroneal nerve
D. Lateral tibial plateau
Case #4
Justin, a 25-year-old male graduate student, was playing flag football the day
before with his classmates when he sustained a twisting knee injury. He describes the
injury as occurring when he tried to avoid another player and his knee “buckled”. He
felt immediate, intense pain on the anterior and lateral surface of his knee and
developed an effusion of his knee within a few hours. Radiographs of his knee were
obtained which demonstrated a Segond type fracture at the lateral proximal tibia.
A Segond fracture is most commonly associated with a tear of what intra-articular
structure?
A. Anterior cruciate ligament
C. Medial meniscus
B. Posterior cruciate ligament
D. Lateral meniscus
Case #5
Sarah, a 21-year-old female, was referred by her primary care physician for knee
pain. She states that she noticed the pain last week after she went on a 5 mile run on
uneven ground. The pain has been a constant, dull ache since that time but she noticed
some relief with rest. While walking, she feels the pain get worse. She notes some
swelling and tenderness and she points to the proximal aspect of the medial tibia, distal
to the knee joint line.
Which of the following superficial structures is NOT part of the superficial medial
knee structures which should be palpated as part of one's physical exam?
A. Adductor tubercle
C. Gerdy's tubercle
B. Pes anserine bursa
D. Semimembranosus bursa
Case #6
A 13 year-old male is brought to your office by his concerned mother. The
patient started running hurdles for his middle school track team last month. He
complains of bilateral knee pain. He has never had this pain before and states he thinks
it’s because he has never this type of exercise before. The pain is located over the
prominence just distal to the joint line on the anterior aspect of the tibia bilaterally.
Physical exam of both knees reveals normal ligamentous integrity with no joint
effusion, but very tight hamstring tendons.
This case describes pain at the tibial tubercle at the attachment of the patellar
tendon. What types of injuries/conditions commonly present at this site (select all that
apply)?
A. Osgood-Schlatter's syndrome
D. Baker's cyst
B. Tight hamstring muscles
E. Quadriceps weakness
C. Iliotibial band friction syndrome
Case #7
A middle-aged male patient arrives in the emergency room after a motor vehicle
crash. The patient’s car was exiting a parking lot when it was run into on the passenger
side, where he was seated. The patient claims that neither car was moving at high speed
but his door was bashed in. He has significant pain and swelling over the lateral aspect
of the knee. The dorsalis pedis and posterior tibial artery pulses are present bilaterally;
however, the patient has decreased sensation over the dorsum of the foot and
decreased ankle dorsiflexion strength.
Which structure running just posterior to the fibular head could explain the patient’s
symptoms?
A. Anterior tibial artery
C. Peroneal artery
B. Common peroneal nerve
D. Sciatic nerve
Case #8
A 53 year-old woman comes in for a 6 month follow-up after a repair of a medial
collateral ligament injury. Her postoperative course was unremarkable until now. She
states that she is currently having medial knee pain that started just one month ago. She
was compliant with the physical therapy regimen until 2 months ago, when she quit
because she didn’t think it was helping. Physical exam reveals tenderness to palpation
over the proximal medial tibial surface.
Which diagnosis is most likely to be missed in this case, incorrectly attributing her pain
to her previous injury?
A. Adductor magnus tendon injury
C. Bakers cyst
B. Pes anserine bursitis
D. MPFL injury
Fibers from what tendons make up the pes anserinus?
A. Gastrocnemius, sartorius, semimembranosus
B. Gracilis, sartorius, semimembranosus
C. Gracilis, semimembranosus, semitendinosus
D. Gracilis, sartorius, semitendinosus
Case # 9
A 20 year-old male comes to your office on crutches after playing in a college
football game. He states that during the game he was tackled from the right side while
his right knee was in full extension. He has significant pain and 2+ extra-articular
effusion on the medial side of his knee. Physical exam reveals pain and laxity upon
valgus stress of the right knee. His Lachman test is normal upon bilateral comparison.
McMurray and Apley compression tests do not elicit pain or crepitus; however pain is
indicated on Apley distraction when the lower leg is placed into external rotation.
Injury to which structure(s) of the medial knee would you suspect the athlete has
sustained?
A. MPFL tear
B. MCL tear
D. ACL tear
E. All of these
C. Meniscus tear
Case #10
A 17-year-old female volleyball player injures her right knee during the fifth match of a
2-day tournament. She describes her MOI as jumping at the net and landing awkwardly.
She “heard and felt a pop” in the knee with immediate pain and swelling. She was NWB
on the involved leg and had to be assisted off of the court. During your physical exam,
the athlete is too tender and guarded to perform a Lachman test. Full extension and
flexion is lacking during active and passive ROM. A positive anterior drawer is noted
with a “spongy feeling end point”. Appley compression is painful at 60 and 30 degrees.
Valgus test at 0 degrees is positive for laxity at 20 degrees is positive for pain.
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