2.2 Knee, Hip & Lower Extremity Conditions

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

2.2 Knee, Hip & Lower Extremity Conditions

Key Takeaways Explain This Topic AI

Lachman test is the most sensitive physical examination test for acute ACL tears, while Thessaly test demonstrates the highest overall diagnostic accuracy for meniscal tears.

Dial test differentiates isolated Posterolateral Corner (PLC) injury (increased external rotation at 30° only) from combined PCL and PLC injury (increased rotation at both 30° and 90°).

Greater Trochanteric Pain Syndrome (GTPS) represents gluteus medius/minimus tendinopathy rather than isolated bursitis, evaluated via the single-leg stance test.

Plantar fasciitis causes severe post-static dyskinesia ('first-step morning heel pain') at the medial calcaneal tubercle, acting through the Windlass mechanism.

Last updated: July 2026

2.2 Knee, Hip & Lower Extremity Conditions

Lower extremity musculoskeletal conditions are major sources of pain and functional disability managed by PM&R physicians. Establishing a precise diagnosis requires integrating functional biomechanics with validated physical examination maneuvers.

Meniscus Tear Diagnostics

The menisci provide load transmission, shock absorption, joint lubrication, and secondary stability to the knee. Meniscal vascularity is divided into three zones: outer red-red zone (vascular, high repair potential), middle red-white zone , and inner white-white zone (avascular, managed with partial meniscectomy).

Clinical Physical Examination Tests

Joint Line Tenderness : Palpation along medial and lateral tibiofemoral joint lines possesses the highest overall sensitivity (~83-85%) for meniscal pathology.

McMurray Test : Patient supine with hip and knee flexed. For medial meniscus , examiner externally rotates tibia with valgus stress while extending knee. For lateral meniscus , examiner internally rotates tibia with varus stress while extending knee. Positive finding is palpable/audible click or joint line pain.

Thessaly Test : Weight-bearing test performed with patient standing on one leg flexed to 20°. Patient rotates body internally and externally three times. Repetition of joint line pain or locking has highest overall diagnostic accuracy (~89-94%).

Apley Grind Test : Patient prone with knee flexed 90°. Examiner applies axial compression while rotating tibia. Pain indicates meniscal injury.

Knee Ligamentous Stability Testing

Knee stability depends on the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL).

ACL Testing

Lachman Test : Performed with knee flexed 20–30°. Examiner stabilizes distal femur and pulls proximal tibia anteriorly. It is the most sensitive test (~95%) for ACL rupture.

Pivot Shift Test : Highly specific test for ACL insufficiency evaluating rotatory instability. Valgus stress and internal rotation applied to extended knee while flexing; at 20–30° flexion, subluxated anterior tibia reduces posteriorly via iliotibial band traction.

Anterior Drawer Test : Performed at 90° knee flexion; less sensitive than Lachman due to hamstring spasm and meniscus blocking displacement.

PCL and Collateral Testing

Posterior Drawer Test : Performed at 90° flexion; most sensitive maneuver for isolated PCL tears.

Posterior Sag Sign (Godfrey Test) : Patient supine with hips/knees flexed 90°. Posterior dropping of proximal tibia relative to femur indicates PCL insufficiency.

Dial Test : Measures passive tibial external rotation at 30° and 90° knee flexion. Increased rotation (>10°) at 30° only indicates isolated Posterolateral Corner (PLC) injury. Increased rotation at both 30° and 90° confirms combined PCL and PLC injury .

Valgus / Varus Stress Testing : Evaluated at 0° (testing collateral plus cruciate/capsular restraints) and 30° flexion (isolating MCL with valgus stress or LCL with varus stress).

Patellofemoral Pain Syndrome (PFPS)

Patellofemoral Pain Syndrome (PFPS) is characterized by retropatellar or peripatellar pain resulting from altered patellofemoral joint mechanics and excessive focal cartilage stress.

Biomechanical Etiology and Risk Factors

Contributing factors include vastus medialis obliquus (VMO) weakness, tight lateral retinaculum, tight hamstrings/gastrocnemius, increased Q-angle (>15° men, >20° women), foot pronation, and weak hip abductors/external rotators.

Clinical Manifestations and Exam

Pain aggravated by stair descent, squatting, running, and prolonged sitting with flexed knees ( "theater sign" ).

Patellar Compression (Clarke) Test : Pressing patella inferiorly into trochlea while contracting quadriceps.

Patellar Tilt Test : Elevation of lateral patellar border; inability to tilt above horizontal indicates tight lateral retinaculum.

Rehabilitation : Focuses on hip abductor/gluteus medius strengthening, core stability, VMO activation, and patellar taping (McConnell taping).

Hip Osteoarthritis and Labral Pathology

Hip disorders manifest as anterior groin pain radiating to the anterior thigh or knee (obturator nerve distribution).

Hip Osteoarthritis (OA)

Characterized by progressive cartilage loss, subchondral sclerosis, osteophytes, and joint space narrowing (typically superior/anterior). Exam reveals restriction of passive range of motion in a capsular pattern: Internal Rotation and Flexion are lost first.

Femoroacetabular Impingement (FAI) and Labral Tears

Cam Impingement : Aspherical femoral head-neck junction bump.

Pincer Impingement : Acetabular overcoverage.

FADIR Test (Flexion, ADduction, Internal Rotation) : Highly sensitive screening maneuver for anterior labral tears and FAI. Groin pain indicates a positive test.

FABER / Patrick Test (Flexion, ABduction, External Rotation) : Posterior hip/SI joint pain indicates sacroiliac dysfunction; anterior groin pain indicates intra-articular hip pathology.

Greater Trochanteric Pain Syndrome (GTPS)

Greater Trochanteric Pain Syndrome (GTPS) primary pathology is gluteus medius and gluteus minimus tendinopathy or tear, with secondary bursa inflammation.

Clinical Signs and Diagnosis

Point tenderness over posterior aspect of greater trochanter.

Pain provoked by resisted hip abduction and passive hip adduction.

Single-Leg Stance Test : Standing on affected leg for 30 seconds reproduces lateral hip pain (high specificity ~92%).

Trendelenburg Sign : Weakness of stance-phase gluteus medius causes contralateral pelvic drop.

Plantar Fasciitis

Plantar fasciitis is a degenerative enthesopathy at the origin of plantar aponeurosis on the medial calcaneal tubercle .

Biomechanics and Clinical Presentation

Plantar fascia functions via Windlass mechanism : passive dorsiflexion of hallux winds plantar fascia around first metatarsal head, elevating longitudinal arch.

Hallmark Symptom : Severe post-static dyskinesia—pain with first steps in morning or after sitting, which improves after warming up.

Exam : Point tenderness over anteromedial calcaneus; pain reproduced by passive toe dorsiflexion.

Management : Stretching plantar fascia and calf muscles, night splints (5° dorsiflexion), custom orthotics, and physical therapy.

Lower Extremity Test Pathology / Target Examination Method Diagnostic Value

Thessaly Test Meniscal Tear Single-leg stance at 20° flexion with body rotation Highest overall diagnostic accuracy for meniscus

Lachman Test ACL Rupture 20–30° flexion, anterior tibial translation Most sensitive clinical test for ACL tears

Dial Test PCL vs PLC Injury Tibial external rotation at 30° vs 90° flexion 30° only = PLC; 30° & 90° = PCL + PLC

FADIR Test FAI / Labral Tear Passive Flexion, Adduction, Internal Rotation Highly sensitive screening test for hip labrum

Single-Leg Stance Gluteal Tendinopathy Stand on affected leg for 30 seconds Highly specific for gluteus medius pathology