DIP Episode 620 - USMLE MSK Series (Knee, Hip)

Welcome, my name is Devine. This is episode 620 of the Divine Intervention Podcasts. In today's podcast we're gonna be addressing the knee, hip and ankle. So this is a continuation of the series on a USMLMSK. These are things that are tested many times if you just know what the USML is required or know. You're typically gonna be in good shape for the exams. So we've done elbow, we've done neck, we've done back. Again if you missed that episode I'll encourage you to listen to it but to them I'm gonna hit knee, hip and ankle. Alright so what are the classic knee pathologies, friends and the MBM Es love to test. So say for example they give you a question about literally a woman and this woman is like in her 20s or 30s. The person is an athlete. The person is you know person that's very physically active and then you're told that this person has pain around their knee. In fact sometimes they can make these questions very non-specific. They tell you that this person has been around their knee and that whenever they run it makes the pain worse or whenever they're going downstairs it makes the pain worse. Well after they've sat for a long time it makes the pain worse. When you see something like this what should you be thinking about? I really hope you're saying that divine this sounds a whole lot like Patelo femoral pain syndrome. Patelo femoral pain syndrome. It's something you want to make sure you can recognize for your exams.

Typically we're gonna find it in women on the USML Es and then usually it's gonna be young women that are physically active. Usually they're gonna be you know 20s, 30s you know people that are very physically active. When you see something like that I want you to think of Patelo femoral pain syndrome. Again they can make the knee pain very non-specific. Basically they just have pain around the patella. That's why it's called Patelo femoral. So just you know sometimes you may even see the term on your exams that it's peri-patel or pain. Peri-patel. The word peri-patel just means around the patella. Okay around the patella. Okay again it's gonna be in a person that is young. Typically a person that is you know less than each 45 or thereabouts on your exams. Right and how do you confirm the diagnosis? This is something you're gonna be doing a clinical diagnosis for. Right? Just basically press against the patella. Press against the patella if you can reproduce their pain or you try to move the patella up and down, up and down, up and down and you're produced their pain. It likely have patella femoral pain syndrome. Okay and the thing is if they ask you or what's your most appropriate next step in management. Literally all you need to do is follow a few conservative measures. Right? Like the activities that work in the pain, high impact around it and all those things avoid those things right. Activity modification is a big one.

Second thing you should keep in mind is that you should try to strengthen the muscles around the knee joint. The thing is when you strengthen you know just like we have pelvic floor muscles where if your pelvic floor muscles are weak you know you're gonna start having things like pelvic organ prolapse or all these kinds of incontinence right? Your pelvic floor muscles are very important support structures for your pelvic organs. Well the thing is your knee joint also has some muscles that are kind of important for structure and support. So if you have patella femoral pain syndrome it's helpful to strengthen those muscles around the knee joint especially the quadriceps muscles right especially the quadriceps muscles. We call these things quadriceps strengthening exercises. They're very helpful for patella femoral pain syndrome. It's gonna strengthen it's gonna basically give your knees good support right and you're less likely to have this pain. Right? You can also ice the knee joint you can use and set you know all these things are perfectly fine as management for patella femoral pain syndrome. Is there another condition that you manage well by strengthening the muscles around your knee joints? It's actually just osteoarthritis right? So like for example if you have knee osteoarthritis right you know your joints are kind of rubbing against each other. You can try to give that joint better support by doing quadriceps strengthening exercise.

Now what if they give you a question about a patient and they tell you that this patient you know for the past few days he hasn't been having pain just in front of his knee right? He has been having a lot of pain just anterior to the knee and then they tell you that he has also noticed that he has had a lot of swelling just anterior to the patella right? So pain notice the key feature here is anterior anterior anterior they have pain in the anterior knee right and again just anterior to the patella they have a lot of swelling right? When you see something like this I want you to think of pre-patella bursitis right? I want you to think of pre-patella what? Bursitis right? Pre-patella bursitis is just pretty much inflammation of a bursa right? A bursa it's inflammation of a bursa so it can present with swelling remember if you remember from step one you know when you were probably you know studying the antecedents of inflammation right? You know there's color there's rubber right? So color means heat it's hot there's rubber right? There's a dollar right? You know so there's all these things right? So there's color there's tumor tumor is another one right? There's swelling right? There's color that's you know it's hot it feels hot right? There's because many of these inflammatory molecules are are pyrogyntes right? There's color there's tumor that means swelling right? There's rubber there's dollar right?

You know there are all these terms you you can look up with these terms mean I'm not here to translate Latin for you right? We're gonna see pain anterior to the knee right? And you're gonna see swelling you're gonna see swelling right? Now the thing is if they give you a question like this when they ask you for your next best step right? And again think of pre-patella bursitis pre-patella before the patella bursitis what should you do on your exams? Go ahead and ask for it that bursa go ahead and ask for it that bursa right? Because sometimes when people have pre-patella bursitis it's actually because they have an infection right? So you just want to make sure that they don't have an infection because if they had an infection you would obviously want to do something about that infection you don't want it to brew and destroy that patella right? And especially you should be worried about infection when the person's pre-patella bursitis is acute. If a person has like a very acute presentation of pre-patella bursitis you should really really be concerned about infection right? You should really really be concerned about infection right? But if you notice that their symptoms are chronic right? It's been going on for a while it's probably not going to be infection right? It's probably going to be like just from some kind of activity they've been doing right?

Let's say for example a person nails very often you know let's say for example a person is a florist or a gardener or a person that works on the floor and the nail-nil-nil often right? Or a person that plays with kids right? That can cause you to have pre-patella bursitis right? That can cause you to have pre-patella bursitis right? Or sometimes you can have trauma to the knee that can cause the problem right? Okay now what if they give you a question about a patient and you're told that this patient that they have this knee pain you know they tell you that man for a couple of days been having this pain on my knee right? And they tell you that they have this pain on the inside of their knee below the knee joint on the what on the inside of their knee below the knee joint? In that circumstance you want to think about something called a PES answering bursitis right? PES answering bursitis. PES answering bursitis. Sometimes on the exam so the PES is spelled as PES or sometimes they may just call it answering right? So ANSE RIN E answering bursitis right? What is the classic presentation? Again the the meme of the game with MSK is just knowing the classic presentation. If you know the classic presentation you're going to be set for these questions on your exams. The pain is going to be on the inside of the knee below the knee joint. It's medial knee pain. Medial knee pain okay? So literally they'll tell you the inside of the knee hurts and it's below the joint.

It's below the joint. It's below the joint right? And many times these people they'll have this pain that happens with with with um you know it's worse in by activity right? And sometimes the pain can be worse at night. The pain can be worse at night. The pain can be worse at night right? And typically we tend to find this in again you can find it in people of four ages but many times right? You may see this in a person that is older right? Remember how I said that patello femoral pain syndrome classically tends to be in an younger person answering bursitis tends to be in an older person but it can also be in young people right? So please don't take these as had and fast-roses don't say. Divine said that patello femoral pain syndrome can never be in an older person. No it can be in an older person more classically you'll be in a young person answering bursitis classically will be in an older person that may have like osteoarthritis. osteoarthritis has a very strong association with answering bursitis with answering bursitis right? And honestly what you need to do for these people is just rest that rest ice ends it right? That's it that's like the name of the game for many of these musculoskeletal disorders rest ice and ends it rest ice and ends it.

Now let me ask you are there two other pathologies that you need to know for your US Emily exams but these are more pediatric things where do you have pain that is in their extremities that is worse at night and relieved by a sedamin of it? Well I really hope you're saying oh divine yeah you know for kids especially if it's by like bilateral calve pain by lateral extremity pain or worse at night relieved by a sedamin of it. I'm gonna be thinking about growing pains right? And then also remember that if you have an osteoarthritis you'll have like calve pain as well typically it's gonna be unilateral you know lateral calve pain and you may pop it up on a bonimass right? osteoarthritis tumors they're also worse at night and they also relieved by a sedamin of it. All right now what if they give you a question about a person right? So you notice we talked about the medial knee we say that hey man if you have been around your medial knee just below the knee joint that's answering bursitis well let me ask you this what if they give you pain at the lateral knee right? Detail you that the pain feels like a knife right? Very sharp pain right the person is complaining very sharp pain on the lateral knee right? And detail you that the thing that really makes it bad is when the run right? When the flex and extend the knee flex and extend the knee flex and extend the knee flex and extend the knee like in running right?

When you see something like this I would really hope you're thinking of IT band syndrome right? Iliotibial band syndrome Iliotibial band syndrome right? Lateral pain on the knee lateral pain on the knee right? And this again conservative measures rest stretching rest stretching right? So you see we've talked about in front of the knee we said pre-partelabercitis or anywhere around the knee right? Worsen by you know running going downstairs sitting for a long period of time we say that's Patelofemero pain syndrome right? We said medial we said answering Mercedes lateral we're saying Iliotibial band syndrome right? Just recognize these things these things are easy points on your exams if I'm being honest with you these things that easy points on your on your exams right? And then don't forget about your ligament tears right for the knee don't forget about your ligament tears right? Remember for the knee there's the ACL there's the PCL there's the MCL you know so you got you got to know those those things right? There's also the LCL the lateral collateral ligament and again the key thing you're going to see on your exams is you're going to see a popping sensation right? Prison's going to say that hey I had this popping sensation and then I just started having this really considerable pain right? And the thing is many times there's going to be a large collection of fluid that develops very quickly they're going to have like this big effusion right?

And again the thing is these these are things you should be easily able to diagnose right? Because normally like I mean you can try this again don't don't don't don't don't be crazy right? But just try this if you move your knee joint like extend out like you know put your knees at 90 degrees try to move your knees forward and backwards and from side to side I'm literally doing it as I'm making this podcast right now you need should be pretty stable you shouldn't have a lot of give you shouldn't have a lot of give right? You shouldn't have a lot of give right? But if they tell you that while you stabilize the person's knee right? And you pull the knee forward you pull the knee you know you pull the knee you pull the so you you stabilize the person's thigh right? The distal thigh you stabilize it with your hand you know and again the the knee joint is at 90 degrees right? You stabilize the person's thigh you know with your hands and then you hold the person's knee and try to move it forward move it forward move it forward what am I doing? That's the anterior drawer sign right? That's the anterior drawer sign we're trying to challenge the ACL if you see a lot of give with that anterior drawer sign right that person has an ACL tear right? If you do the reverse thing you hold the person's knee right?

While again 90 degrees right 90 degrees you hold the person's thigh distal thigh very firmly and then you move the person's knee backwards and you get a lot of give that's a PCL tear that's a posterior collateral ligament tear right? That's a PCL tear that's a PCL tear right? That's a PCL tear right? And then you know think about this what if you try again we've looked at four-den backwards we've literally looked at four-den backwards how about side to side? Let's do side to side right? Let's do side to side these things are not hard you're fairly straightforward right? Let's say you push immediately right? You push the knee immediately so that means you put your hands on the outside of the person's knee on the outside on the lateral side and push it immediately push it immediately if you push it immediately and you get a lot of give right? It means that man that medial part must be weak that MCL must have been torn the medial collateral ligament what exactly do I mean by pushing the knee from the outside? Well what I mean is that you're giving a valgus stress a valgus V-A-L-G-U-S a valgus stress is a lateral stress right? When you give a lateral stress you interrogate the the the integrity of your medial knee but if you give a medial stress a varus V-A-R-U-S a medial stress you interrogate the lateral integrity of the knee right? so if you apply a valgus stress right? L in valgus and L for lateral right?

You push laterally on the knee and you have a lot of give immediately that's an MCL tier right? But if you apply a medial stress right you're pushing the knee from the inside right? A medial stress a varus stress and the lateral knee has a lot of give that's an LCL tier that's an LCL tier okay? All these maneuvers basically just test how stable are these ligaments right? How stable are these ligaments? Now to be honest with you if they ask you for the management just in general for ACL tiers those people probably will need some kind of surgery right? People that have ACL tiers they're probably gonna need some kind of surgery they're probably gonna need some kind of surgery right? But for most of the other tiers like MCL, PCL for example just conservative management right? Just conservative management that's literally all you need to do right? And then let's talk about the tier in a meniscus let's talk about meniscus tiers right? Let's talk about meniscus tiers again the key thing you're gonna see is pain along the joint line pain along the joint line pain along the joint line right? Pain along the joint line right? And many times you may see terms on your USML exams like locking you know grinding right? Like it's almost like the knee is like locking right? It's like you move the knee and then it kind of locks up right? When you see that description they're probably describing some kind of meniscus tier right?

And again the key tenderness you're gonna see on your exams is pain along the joint line on the affected side right? So say for example if you have pain along the medial joint line that's a medial meniscus tier you have pain along the lateral joint line that's a lateral meniscus tier right? That's a lateral meniscus tier right? And here's the thing the the the way they're gonna describe that you make this clinical diagnosis is you literally extend the person's leg fully right? You extend their leg you pretty much hold out their legs straight so the knee joint is completely straight right? And then try to you know hold their distal thigh right? Hold their distal femur and then take their legs right? Their legs and try to rotate it in a circular fascia try to rotate it in a circular fascia try to rotate that tibia and you notice that they have like this locking this catching right? This grinding right? And again they will have tenderness around the affected joint line if they have tenderness around the medial joint line right? That's a that's a medial meniscus tier they have tenderness around the lateral joint line that's a lateral meniscus tier okay? And generally for these people you don't have to do any major crazy thing right? Most of the time all you need to do for them is rest, ice strengthen the muscles around those joints rest, ice and strengthen the muscles around those joints right? Strengthen the muscles around those joints okay?

But if you try all these things for weeks right? You've tried these things for weeks for weeks for weeks right? Especially if you've tried these measures for like a month and you're still not improving then in that case you should consider surgery although before you do surgery you want to kind of know what's going on right? So it's helpful to do some kind of imaging right? Typically you're going to do an MRI right? But please please please only pick this MRI if surgery is what you're planning to do. If you're not planning to do surgery on this person just recommend rest, ice, strengthen the muscles around that joint okay? That's literally what you do in these circumstances on your exams. Alright now let's talk about the hip. I have a feeling that I'm not going to be able to get to ankle because I have something I need to literally run to in a few minutes here right? But hip, hip, hip the big thing is to know about hip right? If they give you any question about hip pain in a person with the following risk factors what should you think about? So let's say for example they give you a child that has had a lot of had a lot of emergency room visits for just like diffuse pain all over their body right? And then they tell you that man for the past a couple of days they've been having just really bad pain in their hip really bad pain in their hip right?

Or you see like the same presentation really bad pain in the hip in a person that has cirrhosis right in a person that has cirrhosis well a lot of the person has to have cirrhosis probably because they have big time alcoholics right? Probably because they have big time alcoholics right? Or you see this in a person that has like oh they're like man I have very severe pain in my hip and this person has been on pharmacotherapy for the longest time for giant cellaritis because we have giant cellaritis you're gonna be on those high dose steroids for a long time long long long time when you see all those kinds of things I want you to think of a person having osteonecrosis right? Think of a person having osteonecrosis of the hip right? They love to test it with risk factors on the USM exam so what are the classic risk factors for hip osteonecrosis? Well the person that has the pain everywhere right? That's a sickle cell patient right? Sickle cell disease with those pain crises right? A person that is an alcoholic right? That's the person that has cirrhosis alcoholism sets you very beautifully for osteonecrosis of the hip right? Or you see a person that uses steroids for a prolonged period of time you know like an asthma patient that has severe asthma and they're taking like chronic oral steroids or a person that has giant cellaritis right? That's the person that you know you know you know taking steroids for a very very long time when you see something like that right?

Think of osteonecrosis think of osteonecrosis that that that person has you know just death you know I'm also you can find these in people that have a lupus right? You know osteonecrosis poor blood supply to the femoral head raise to the femoral head cannot cannot dyes right? And if you want to diagnose osteonecrosis get an MRI get an MRI get an MRI right? What are you gonna see on an MRI? You gonna see that femoral head looks necrotic sometimes it can be completely flat it can be completely flat okay? It can be completely flat right? That's something I want to make sure you know for your exams okay? Make sure you know this for your for your exams right? Again there is factors, lupus, sego cell, using steroids, big-time alcoholic that can cause problems right? And again a lot of the time a lot of the time these people are probably gonna need surgery at some point they're probably gonna need replacement of that hip joint the hip joint is thankfully one of those joints you can replace right? And what if they give you a question about a patient and this patient has a issue of like breast cancer or prostate cancer or whatever and they're having a lot of hip pain think of meds to the hip believe it or not some of these cancers can actually make us the size to the hip they can actually make us the size to the hip right?

And then what if they give you a question about a patient and they tell you that man this patient has a lot of tenderness around the I mean around the lateral hip a lot of tenderness around the lateral hip lateral hip lateral hip lateral hip they're like man I have a lot of tenderness around my my hip have a lot of tenderness around my hip right? Especially the lateral hip right? And it's almost like pinpoint tenderness around the lateral hip right? And this person says that hey I can I can move my hip completely fine I don't have any issues with range of motion but man when I try to AB docked my hip AB docked right? So moving your hip outwards moving your hip outwards and you have a lot of pain then I want you to think of trochanteric Mercedes trochanteric Mercedes trochanteric Mercedes now as you've seen me say many of my podcasts and I do this a lot in my classes the USM is sometimes they'll have like alternate names for things right? You have like alternate names for things um another name you may see on your exams for trochanteric Mercedes is something called greater trochanter pain syndrome GTPS greater trochanter pain syndrome GTPS okay? The way you're going to manage this for the most part is just a set of menophanor insets right? That's perfectly fine right? If that doesn't work you can inject steroids into the you can inject steroids into the joint right? And then again don't forget many of these um um hip problems that can happen in kids right?

Don't forget you see a child newborn has a hip that is very claky right? Any hip problems in a newborn right? Should make you think of developmental dysplasia of the hip right? Basically the acetabulum is very flat right? So the femur uh cannot fit very well into it right? You're gonna treat out a public harness a public harness right? And then if you see a child that has um a lot of hip pain right and this child is under H 10 right? This child is under H 10 right? You have a lot of hip pain right? You want to think of leg-covy-perthes disease leg-covy-perthes disease but if you're over H 10 especially in an obese child and obese child that has hip pain right? Think of sciffy slip capitol femoral epiphysis okay? Think of slip capitol femoral epiphysis right? And please don't forget because we kind of talked about osteonecrosis with alcoholism with lupus with sickle cell disease with steroid use don't forget that leg-covy-perthes disease is another kind of osteonecrosis please this is like florically high yield to know for your exams leg-covy-perthes disease on your exams instead of them putting leg-covy-perthes disease as an answer they can just put hip-osteonecrosis as the answer and that'll be the right answer they're going after on your exams it's classically going to be in a child that is under age 10. Classical going to be in a child that is under age 10 all right?

I think I'm gonna go ahead and and stop here um because again I have to run to something maybe I may say one or two more things about the hip uh next time but uh ankle will have to be addressed in another podcast when I get the opportunity to make that podcast so this is a uh me and hip podcast right but again these things are very high-yield you know you're gonna see this on your exams you know maybe they may be one or two more concepts I want to talk about with the hip uh probably address that in a future in a future podcast in a future podcast what that podcast will be when it will be I don't know but it'll be in a future podcast god will it and I offer a bunch of review classes that I think can be fine to be helpful um for example uh tomorrow I actually have a test taking class right so now probably be the last test taking class that comes in good proximity to an era's application right if you want to get your scores in you should be taking the test taking class uh many people have taken it found it to be really helpful right and then on Wednesday I have a bio stats class right on Thursday uh that's a four hour class on Thursday I have a social sciences quality improvement healthcare systems ethics class um it's a five hour class and then on Friday I have a last minute review the class tomorrow Wednesday on Thursdays for step one order with step three right and then on Friday the last minute reviews for step two and step three and then next week from Wednesday to Sunday from Wednesday to Sunday you know five days four hours each day I have a 20 hour step two step three review if you're taking step two step three you want to get your scores in before eras that is the class you should take right that is probably going to be the last class uh the last step two step three class uh for you to take your exams on time to get your era scores back you know get your step tw

o step three scores back on time for eras um I also offer one or one to learn for the US Emily and complex exams and then I um help with eras applications mock interviews personal statements retliners and things like that um and then I have another website called divineinterventionlifelessons.com divineinterventionlifelessons.com every week I post like one or two podcasts where from a biblical perspective uh address a life lesson many of you know I'm a christ follower I'm a christian uh proud to be a christian and uh I post podcasts life lessons podcast there's actually almost like 360 podcasts on there um divineinterventionlifelessons.com there's actually an Apple podcast associated with that I'll call the divine intervention life lessons podcast so thank you for listening to me today I will see you God willing in episode 621 so have a wonderful day i'll go bless you and bye for now thank you

Young, physically active women (20s-30s).

Infection (Septic process), requiring urgent evaluation.

Valgus stress test (applying lateral force to the knee).

Medial aspect of the tibia, below the joint line; often associated with overuse or trauma.

Chronic alcoholism/cirrhosis, prolonged steroid use (e.g., high-dose steroids), and sickle cell disease.

Lateral Collateral Ligament (LCL).

Around the patella (e.g., peri-patellar pain).

Rest, Ice, and Strengthening exercises.

Lateral knee pain, often described as a sharp "knife" sensation, worse with running/flexion-extension.

Legg-Calvé-Perthes Disease (LCPD).

Necrotic appearance or flattening of the femoral head.

Pes Anserine Bursitis.

Around the patella (e.g., peri-patellar pain).

Rest, Ice, and Strengthening exercises.

Lateral knee pain, often described as a sharp "knife" sensation, worse with running/flexion-extension.

Legg-Calvé-Perthes Disease (LCPD).

Necrotic appearance or flattening of the femoral head.

Pes Anserine Bursitis.