DIP Episode 310 - The Floridly HY Knee Exam and Pathologies Podcast (for all USMLEs)

Okay, welcome. My name is Divine. This is episode 310 of the Divine Intervention Podcast. And in this podcast, I'll be going over a topic that is ridiculously extremely high yield for the USML1, step 2, 3, and step 3 exams. I'm going to call this the Clutch Knee Exam Podcast. Basically, if you listen to this podcast, because I mean, many of you know this, right? If you take the USML exams, they always love to do these things where they will describe different knee examination maneuvers. Excuse me. And then they will try to get you to make a diagnosis based on those specific maneuvers. So God willing, my goal today is to go over pretty much all the high yield knee maneuvers that your friends at the NV Me love to test. And I'll just talk about them in context. And I'll give you all the relevant information you need to know. If you listen to this, you should be good to go from this perspective on on exams. And again, I'm going to try to be really make this succinct, but again, just make this very high yield again. I can almost promise you, for those of you taking any of the USML exams, it literally doesn't matter step 1, step 2, see key step 3. And really, if you're taking like your surgery shelf or your emergency medicine shelf or your internal medicine shelf or your family medicine shelf, this is something you're going to find to be extremely helpful.

So in fact, I'll just say this is something you should just listen to if you're a medical student, it will help you out a lot, right? So the thing is, again, I know step 2 CS is now a different exam. It's not something that's done much anymore. It's not done anymore. But you know, some people are taking the complex to PE exam, although they haven't made an announcement on that, I think it's like April 30th, where you're supposed to make some kind of announcement. But basically remember, whenever you're doing a knee exam of any sort, right? You're supposed to inspect first, right? And then after that, you're supposed to palpate, and then after that, you're supposed to do a range of motion, right? So like maybe we use this demonic that you look first, and then you feel second, and then you move third. Okay, and please don't be mad about the thing you may be hearing in the background. It's just some weird act in alarm. I'll have to work on that later. Okay, so first thing I guess I'll talk about is what is a valgus test of the knee, right? What is a valgus test of the knee? Basically, this valgus test of the knee is something that is classically done, right? When a person has a, when a person, you essentially you have them lie on their back, right? So they lie supine. And then the thing that happens is that you then flex their knees about 30 degrees, or let's say 20 degrees, you flex their knees 20 degrees, right?

So you flex the knee flexing the knees almost like creating like creating like a small triangle under the knee, right? So you flex the person's knee, and then you apply a lateral force, right? Remember the L in valgus for the L in lateral. So you're literally pushing on the lateral aspect of the knee, right? The thing is when you apply that lateral force, you're using it to test them, media collateral ligament, right? And again, that will make sense because the media collateral ligament is literally on the opposite side of the lateral force, right? So if it's ruptured or something, that if you have like a ton of displacement, immediately, then that tells you that, oh wow, this person is likely ruptured or torn the immediate collateral ligament, right? Now the opposite is the case, right? A virus test, right? So a virus test again, the president's lying on the back there supine, you flex their knees, right? 20 degrees, right? Again, I know many resources, you see that mentioned 30 degrees, but really for the most part, 20 degrees is the right thing to do, but 30 degrees is not wrong, or 20 degrees is really the right thing to do. So again, the lie on the back and then you apply a media force, right? So that's a virus test, right? Apply a media force, right? If you get excessive lateral displacement of the knee, right? That tells you the person has ruptured their lateral collateral ligament or at least they've torn it of some sort, right?

And the thing is, right, so we've kind of talked about the collateral ligament, well, what's the, what's the, what are those anterior posterior ligaments or what do they mean? What does the enemy kind of want you to know about those? Well, remember that, you know, if you suddenly slow down when you're running or, you know, if you let's say you're running or you're twisting your leg and you suddenly slow down, right? And let's say, for example, the lateral aspect of the person's knee smashed, unfortunately, that can actually tear the person's ACL, right? Or if, for example, the person has like a TBL dislocation posteriorly, that can tear the PCL, right? And the thing is to assess these AC Ls, so anterior cruciate ligament or PCL, posterior cruciate ligament, and tears, right, to use drawer signs, right? So let's talk about the anterior drawer sign and the posterior drawer sign. And then I'll talk about one other sign for an ACL tear, right? Well, basically, for the anterior drawer test for an ACL tear, the person is going to, again, lie on their back, they're going to lie supine, right? But now instead of having the knee joint held in flexion for 90 degrees, they're going to hold it in flexion for, I mean, instead of holding the knee joint in flexion for 20 degrees, they're actually going to hold it in flexion for 90 degrees, right? They're going to hold it in flexion for 90 degrees. And then when you do that, you then pull the TBL forward, right?

So the thing is usually whenever you're doing a knee exam, you want to compare it with the unaffected knee, right? So if you notice that, oh, wow, this TBL moves anteriorly a lot more than the unaffected knee. That's a positive anterior drawer test, the person has an ACL tear, right? But remember for the anterior crushered ligament, and the thing you can do on an MBM exam is actually something called the Lachman test. So let me tell you this. If they give you an MBM question, or you can do it, you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. And then you can do it. So let me tell you this. If they give you an MBM question, or you suspect that a person has an ACL tear, and they put anterior drawer sign as an answer in terms of diagnostic testing, and they put, oh, you know, like physical exam and over, and they put the Lachman test, pick the Lachman test over the anterior drawer test, because it's more sensitive, right? Again, it's kind of similar though. It's just the angle that's a little different, right? So you basically, again, flex the person's knee, but you do 20 degrees, not 90 degrees. You flex the person's knee 20 degrees, and then you pull the TBR forward.

Again, if you have excessive anterior displacement relative to the unaffected knee, that tells you that the person likely has some kind of ACL tear. Now, the thing is there are two higher things to know, namely an exam in relation to ACL tears. The thing is when a person tears the ACL, it actually is usually associated with some kind of fracture of the lateral TBR plateau, right? So like the plateau of the TBR, kind of like the crest of the TBR. On the lateral side tends to tear quite frequently when people have ACL tears. That's one. The second one is whenever a person has a meniscus tear, you need to assess those people on NBME exams for ACL tears, right? Whenever a person tears a meniscus, right? Always, always on NBME exams assess them for an ACL tear, because again, many times a tear in a meniscus is almost all, is not lemon or sea almost oats, but usually associated with an ACL tear as well, right? It's just an association to kind of keep at the back of your mind for NBME exams, right? And then the thing is, you know, obviously you also need to know how to assess the meniscus on NBME exams, right? So let's kind of talk about meniscus tears, right? Meniscus tears. I mean usually the buzzwords you may see in the question is, they may tell you that the person has like a click in or a catch in or a locking of their knees, right? So they may have like a click in, a catch in or a locking of their knees, right? And usually they'll be like joint-line tenderness, right?

So they may have like medial joint-line tenderness or they'll have like lateral joint-line tenderness, right? But again, unfortunately, that's not going to tell you exactly what's going on, because having lateral joint-line tenderness means that you could have a lateral collateral ligament tear or lateral meniscus tear. Having medial joint-line tenderness will also mean that you either have a medial collateral ligament tear or a meniscus tear. Although, if they just give you like medial joint-line tenderness and they don't put both as answers, then whichever one they put is going to be correct, right? Because just by process of elimination, it will make sense that that's the right thing to do, right? So let's talk about the actual diagnostic testing you're going to do for these meniscus tears, right? So the big, big one you want to remember for you exam is the Mach-Mari test, right? The Mach-Mari test is MC, right? MC and then a big M U-W-R-A-Y, right? The Mach-Mari test, right? Basically, the thing that happens again, these people are going to lie down supine, right? They're going to lie them on their back, right? And then they are going to, they are going to essentially put the knees in 90 degrees of flexion, right? And then the thing is you're going to use one hand to support the person's knee, it's very the anterior knee, right? Basically, you're going to place one hand and your thumb, right?

Your, you know, big thumb is going to be on the medial joint line, and then your index finger is going to be on the lateral joint line, right? So you're using, you're going to use your two hands for this test. One hand is going to be on like in front of the knee joint, right? And your thumb is going to be on the medial joint line, your index finger is going to be on the lateral joint line, right? And then you use your other hand to control the person's heel, basically to modulate the person's foot, right? And then the thing is when you then grab the person's heel, apply a VALGOS force, right? So remember, VALGOS force is a lateral force. So you apply that VALGOS force while you're externally rotating the person's leg, right? With that's other hand that's on the foot, right? So apply a VALGOS force, right? Although, hold more the heel, right? Like the back of the foot, right? So you apply, you apply some kind of VALGOS force, right? So remember, that's a lateral force, and then you're using that hand on the foot to try to externally rotate the leg, right? That's how you test the medial meniscus. If we're thinking about the lateral meniscus, it's kind of the same deal, right? You apply a VALGOS force, right? So that's a medial force, right? And then you internally rotate the leg. So let me see how to remember this VALGOS virus, blah, blah, blah, blah, internal external rotation. Let me give you a nice harmonic here, right?

Just remember how you test the lateral meniscus and take all the opposites for the medial meniscus, right? Here's the harmonic I use for the lateral meniscus. I use the term virus, V-I-R-U-S. I literally use the term virus, V-I-R-U-S, right? V-I-R-U-S, V-I-R-U-S, right? That's for the lateral meniscus, virus lateral meniscus, virus lateral meniscus. What does virus mean? Well, the V-I-R will help you remember that, oh, wow, I'm going to apply a virus force, a medial force, right? And then, again, the same virus helps you, like the I-R, it helps you remember that, oh, you're going to do an internal rotation of the presyn's leg, right? And again, the thing is, whenever you're doing both of these maneuvers, right? Again, make sure that one hand is on the knee, and then make sure the other hand is on the presyn's foot, right? Again, one hand on the knee, and the other hand on the foot. And then, I guess one thing I will say is, what you're performing the test, remember I said you start the presyn, you know, the starting position is 90 degrees of flexion. As you're doing the test, I'm doing these, you know, internal external rotation movements, you are slowly extending the presyn's knee, right? So, again, virus pneumonia, right? So, again, virus force, internal rotation, right? Of the presyn's leg, that's how you test the lateral meniscus, right? Valkus force, that's a lateral force, external rotation, that's how you test the medial meniscus, right?

So, again, these are the ways you essentially test these meniscus, right? And again, while you're doing this test, if you hear like a click or a pop, or you have like a catch at the respective joint line, so if it's like the medial joint line, it's a medial meniscus here, if it's a lateral joint line, it's a lateral meniscus here, right? Another test you can also use to test these meniscus, right? Is this thing called the A-P-L-E-Y, right? The A-P-L-E compression test, right? This one, instead of lying these patients on their back, right? That's supine, you're gonna lie them on your belly, right? That's prone, right? So, you place them in the prone position, right? So, the line on the belly, and then you flex the knee to 90 degrees, right? And then, you stabilize those people's hips with one hand, and then use the other hand to, you know, so you stabilize the hip with one hand, kind of keep it flat. And then, use the other hand to grasp their feet, and then compress that foot downwards, right? And while you're compressing those people's feet downwards, internally and externally, or TV and legs, right? Internally and externally, or TV and legs, right? If you notice that, oh wow, while you're compressing their foot downwards, right? Against their knees, and internally and externally rotating the legs, if you notice that, oh wow, they have a lot of pain, right? And that person essentially has some kind of meniscus here.

I mean, under tests that super low use, I'm not really gonna talk about it, I'm just gonna say it for a complicity, it's called the Thessaly test, right? So, THE, double S-A-L-Y, the Thessaly test, it's also used to assess meniscus tears, right? Now, some other things that you may see with the knee joints that I think I should just maybe go ahead and talk about. Again, if they give you a question about a person, and they tell you that, oh, this person, you know, has just had trauma to the person's knee, or the person kneels down a lot. And then they tell you that, oh, the person has like pain, has redness, has swelling, right in front of the patella, right? The thing you wanna think about on Indian exams is that the person likely has some kind of pre-patella versitis, right? They have some kind of pre-patella versitis. And the way you deal with a pre-patella versitis is you just ask for it and you drink that versitis, right? And then, what if they tell you that, oh, a person, you know, was maybe playing sports or whatever, right? And they hear, you hear like a, they heard like a pop sound. And after you heard that pop sound, they are not able to straighten their knees. Basically, they cannot extend their knees. And if you notice that, oh, they tell you in the question that they have a lot of pain, they have a lot of swelling, they have like a palpable defect, right? Along the superior region of the patella, right?

You know, that's basically where the quadriceps are tendin insert. If they give you that presentation on an exam, what should you be thinking about? Well, I really hope you are saying that, oh, these people likely have some kind of quadriceps rupture, right? That's the way a quadriceps rupture will present for you on an end-bim exam, right? So again, the participating in some kind of physical activity, right? They hear a pop and then they cannot straighten their knees anymore, right? Basically, they cannot extend their legs. I mean, their knees, right? If you see that, and again, they have like palpable problems along the superior portion of the patella. You want to think about some kinds of quadriceps rupture, right? They've ruptured, they've ruptured their quads. And then, I want to teach something. These questions really, really, really annoy people, right? Where they'll put many different things. I don't know the end-bim, they have this weird love for the region just below the patella, right? They have this weird love for the region just below the patella, right? Like the inferior border of the patella, right? The inferior border of the patella. So the thing is, I'm going to teach you a very nice trick. If you follow this trick and commit it to memory, you'll be like in excelling shape for these below the patella questions, right? And guess what? I'm going to go from medial to lateral. I'm going to go from medial to lateral, right?

So again, the region I'm talking about here is below the patella, right? Below the inferior border of the patella, right? So if they tell you that, oh, below the patella, a person has tenderness. So I'm going to be talking about different points of tenderness. If a person has tenderness at the medial joint line, right? Again, just below the patella. The person likely has some kind of medial collateral ligament or medial meniscal tier. Okay? That's what you see on the main mimics. Now, let's keep going medially, right? Now, if you notice, just, I mean, you should do this right now to yourself. Well, don't do this while you're driving. Do this if you're sitting in a good position. But basically, if you fill your patella, if you notice below your patella, there's this big bulge, this very solid bone that kind of bulges out just beneath your patella, that is actually the thing called the TBL tuberosity, right? The TBL tuberosity, the TBL tuberosity, right? The TBL tuberosity. Now, between that medial joint line, right? Again, the medial joint line is the medial part, just below your patella, below your patella, right? If you go halfway between that medial joint line and your TBL tubercle, right, your TBL tuberosity, right? And there's tenderness in the middle. So notice, we first started at the medial joint line. That's the most medial. And then we move a little bit to the region that's basically one half the space between the medial joint line and the TBL tuberosity.

If a person has tenderness, midway, right? You should be thinking about something called PES answering, presides, PES being PES, and then answering, being ANSE, RINE, PES answering, presides. But if you then keep going immediately and you tell you that the person has tenderness over the anterior TBL tubercle. That's actually Osgooth Schlatter disease, right? That's going to be Osgooth Schlatter disease. Remember, another buzzword, another name, because remember the MBM Es, they love to use like many names for the same thing. Another name for Osgooth Schlatter disease on MBM Es exams is traction epophysitis. I'll say that again. Traction epophysitis, APO, PHY, SITIS, right? But then if you keep moving laterally, if you have tenderness at the lateral joint line, that's an LCL tier or lateral meniscal tier. So again, and then I guess if you go super, super lateral to the lateral femoral condyle, although this one is higher, it's kind of like a bulldozer battella. If you have tenderness along the lateral femoral condyle, you want to think about something called iliotibial band syndrome. Many times if you know where the tenderness is and usually give this in the question, you know exactly what you're dealing with. And I guess if you go the way to even the back of the knee, if you go to the back of the knee and there's pain, there's swelling behind the knee, you want to think about a big resist. Sometimes you'll see that all day tenderness and swelling in the public heel faster.

If you see that, you want to think about some kind of bigger cyst. So again, let's go from medial to lateral real quick again. Again, medial joint line, just below the patella, think about an MCL, so medial collateral ligament to a medial meniscal tier. And then if you go more medial, again, halfway the distance between the medial joint line and the tibial tuberosity, right? And there's tenderness there, that's pain, answering, Mercedes. If a person has tenderness at the tibial tubercle, right? At the tibial tubercle, the anterior tibial tubercle, that's also good shoulder disease. If they have tenderness on the lateral joint line, right? That's either a lateral meniscal or a lateral collateral ligament tier. If you go super lateral, but you go a little higher, just above the patella, the lateral femoral condyle, and the person has tenderness there, then you can see that the person has iliotibial band syndrome. And then if you go all the way back to the back of the knee, the poteletofossor, and the person has tenderness and swelling there, think about a bigger cyst on an MBM example. And then as I wrap up, how do you assess for a fusion at a person's knee? How do you assess for a fusion at a person's knee? Well, basically what you should do on MBM exams is the, or you know, clinical practice is the milking technique, right?

Although, again, I feel like I should add this disclaimer, this podcast, any of my podcasts that I meant to, they're not made for clinical care, whatever, they are made for example purposes, right? Again, I just feel like I kind of need to throw that disclaimer. Okay, I'm kind of living a string for all these days, right? So in terms of effusions, right? So remember, when you're trying to test for a new fusion, you're gonna milk immediately, right? So basically go to the media portion of the knee joint, and then you milk from bottom to top, right? So you milk, right? So you basically milk from inferior to superior. And then after that, you then milk laterally from superior to inferior, right? So you milk immediately from bottom to top, and then you milk laterally from top to bottom, right? And then if you notice that there's a media bulge, right? The person has, the person has a knee joint, a fusion. And then one final thing I want to talk about as a knee test, you see on your exam, is something called Clark's Test, right? Clark's Test. So Clark is spelled C-L-A-R-K-E, Clark's Test, right? Basically, it's a test where you essentially are stritting the person's legs, right? So extend your knees. And then the thing that then happens is you then ask the patient to try to like contract their quadriceps. How do you contract your quadriceps? Just make your thighs very tight, you know, like, tighten your thighs, right?

And as you're doing that, the examiner is going to be pressing against like this upper part of your patella, the superior part of your patella to basically present prevent it from moving, right? If you notice that, oh, wow, the person has a lot of pain while you're doing this. This is actually an endemic exam. If you see this and they're trying to get you a bigger diagnosis, I want you to think about patello femoral pain syndrome, right? I want you to think about patello femoral pain syndrome on your exam, okay? Patello femoral pain syndrome on your exam. So I think I'm going to go ahead and stop here. Again, in the future, God willing, I'm going to make a lot of orthopodcasts because these bone disorders and stuff, you just kind of messes people up on exams, but it doesn't need to. Most of these bone pathologies actually have like pretty decent pathophysiology behind them, right? So hopefully in the future, God keeping you alive and giving me time, I will be happy to make those podcasts. So again, as I do at the end of every podcast, I do offer one or one to learn from any exams. Step one, step two, seek is step three, pre clinical medical exams, third year clerkship, shelf exams. And then I do help with applications like Euras applications. Again, I've been on an admissions committee for a year and I've wanted lots of people that are now residents that have tricky applications.

So people that were, you know, they failed step one or they failed step two or they don't have research or something to that nation, right? I, or you know, they have all these red flags they graduated 10 years ago. If any of those situations applied to you, I've worked with lots of people in those categories that are now residents, right? And even for the super competitive specialties, neurosurgery orthopedic surgery, E and T, dermatology, right? I mean, I have literally worked with even people from backgrounds, right? Like academic backgrounds, less severe, much less super well ranked, right? That have matched into these competitive specialties. So again, if any of these things applies to you, just shoot me an email through the website and I'll be more than happy to point you in the right direction. And then I also have these my videos on You Tube, right? Have a You Tube channel, Divine Intervention, USMLE podcast and videos. And then I also have these podcasts on Apple podcasts, Google podcasts and Spotify, at least the most recent 150. So if you're again interested in any of those, just download those podcasts apps, subscribe to the actual podcast itself and you can listen to those. But if you want everything all the way from episode one is going to be on the website, it's a Word Press rely, literally have no control over this, most recent 150 podcasts room. So thank you for listening to this.

I hope you have a very wonderful day and stay strong, be well, take good care of yourselves. And remember that your life is not determined by, is not defined by the score you get on USML Es, right? But again, as you've always seen me say, putting your best work, right? Don't wait for the last moment. I feel like unfortunately there are many met students, many people in healthcare that kind of live things for the last moment, right? When you live things for the last moment, you're very likely going to not do a great job, right? Or you're going to do it and do it poorly, right? So just don't leave things for the last moment, right? Because you see some people, their first two years of met school, they are not doing Gidley squat, right? And then one month before step one, they start panicking, right? And they're asking for all this, oh, what can I do? Can you tell me what my score will be? The thing is, you can kind of know how well you do based on how much good work you put in. Good work, right? Because again, I feel like some people, they work hard, but they don't work smart, right? So you see certain people, they're trying to read a book, where book reading doesn't work for them. Or they try to listen to an audio podcast, where audio podcasting doesn't work for them, right? So again, the thing is you need to find the method that works for you and then when you find it, you need to exploit it to your advantage, right?

And obviously you also need to be good at test-taking from the get to be able to also, you know, do it on these exams. But again, I'll just encourage you, don't leave work for the last minute. I guess that's kind of my life lesson for today. So thank you for listening. I'll see you next time. God bless you. Thank you.

Inspection, Palpation, and Range of Motion (ROM).

Supine, knees flexed (~20 degrees), apply a lateral force. It tests the Medial Collateral Ligament (MCL) because the MCL is on the opposite side of the applied force.

The Lachman Test. This involves pulling the tibia anteriorly while the knee is flexed to 20 degrees, as it is more sensitive than the Anterior Drawer Test.

Meniscus tears are often associated with an ACL tear, and an ACL tear is frequently associated with a lateral tibial plateau fracture.

V-I-R-U-S (Valgus force/Medial force applied while Internally rotating). Correction: The transcript states V-I-R-U-S is used for the lateral meniscus, which involves a Valgus force and Internal Rotation.

The Milking technique. Medially, milk from inferior to superior; laterally, milk from superior to inferior.

Lateral Collateral Ligament (LCL).

Tenderness directly over the anterior tibial tubercle/tuberosity.

Medial Collateral Ligament (MCL) tear or Medial Meniscal tear.

Apley Compression Test.

Quadriceps tendon (Quadriceps rupture).

Pes Anserine Tendinitis.

Lateral Collateral Ligament (LCL).

Tenderness directly over the anterior tibial tubercle/tuberosity.

Medial Collateral Ligament (MCL) tear or Medial Meniscal tear.

Apley Compression Test.

Quadriceps tendon (Quadriceps rupture).

Pes Anserine Tendinitis.