Transcript (Ankle, Knee and Hip) - Academic Day

Knee & Hip
Examinations
Family Medicine Academic Day
Marie-Josée Klett, MD CCFP Dip Sport Med
Louise Walker, MD CCFP FCFP Dip Sport Med
Department of Family Medicine
University of Ottawa
Confidentiality and Conflict Declaration
Speakers have no conflicts of interest to
declare
This presentation and associated handouts
are for use by University of Ottawa DFM
residents and are not to be used for other
purposes or distributed without the written
consent from the speakers
Knee History
• Role play
Knee History
 Nature of the problem – pain, swelling,
catching/locking, giving way
 Duration
 Mechanism of injury
 Location of pain
 Radiation of the pain
 Aggravating factors
 Relieving factors
 Pain during and/or after activity
 Rx to date; Past Hx; ROS; FHx; Meds;
Allergies;
 “Other”-reason for visit at this time; sporting
history; legal
LOOK
Standing:
Alignment
Knee: Normal, Recurvatum, Holds in Flexion
Varus (finger distance between knees)
Valgus (intermalleolar distance)
Deformity
Visible swelling front or popliteal space
Feet: Pes planus, Pes cavus, Overpronation
Alignment
Feet
Overpronation
Baker’s cyst
LOOK
Walking:
Gait:
PWB
Antalgic favours: Right or Left
Varus thrust
NWB
AIDS: crutches/cane/w/c
LOOK
Sitting
Skin Redness/Blueness/Mottled/Abrasions/Scar/E
cchymosis
Muscle – contract quads- Lateral Tracking
(“J” Sign)
Tibia:
Internal Rotation
External Rotation
FEEL
Palpate Point(s) of Maximal Tenderness:
Bones: joint lines (knee bent), femoral condyles
(knee bent), patellar facets, tibial
plateau/tubercle, fibula
Ligaments: MCL, LCL
Tendons: Patellar, Quad, Hamstring, ITB, Pes
Anserine
Can also feel soft tissue swelling and muscle
bulk (atrophy)
Surface Anatomy: Practice
Pes Anserine
MOVE
Range of Motion: Active, Passive, Resisted
Extension
Flexion
Feel for Crepitus (retropatellar during active
flexion/extension)
Hip screen: at least passive Flex + IR + ER
(Ext/Abd/Add if abnormal)
Special Tests
• Meniscus
• Ligaments
• Patella
Meniscus: Anatomy
Meniscus: History
• Usually specific incident: most often twisting
injury
• Often associated with swelling, can have
catching and/or locking
• Pain with squatting, kneeling, twisting
• Medial or lateral pain but sometimes difficult
to localise
Meniscus: Physical Exam
• Often have small to medium effusion: bulge test
• http://www.youtube.com/watch?v=LsgutijmX7
U
• Pain with passive flexion OR 2.3
• Joint line tenderness Sens 76% Spec 29%
Meniscus: Physical Exam
• McMurray: externally rotate and abduct for
medial, internally rotate and adduct for lateral,
click with pain is positive.(Sens 52% Spec
97%)
• Thessaly: twist on affected knee with 20o of
flexion, pain is positive. (Sens 96% Spec
95%)
• Apley Grind: patient prone, apply load to knee
and grind, pain is positive. (Very little data)
Meniscus: Thessaly
Practice
•
•
•
•
Passive flexion and extension
Bulge test
McMurray’s
Thessaly’s
Ligaments: Anatomy
MCL: Anatomy
ACL: Anatomy
Ligaments: History
• Mechanism of injury:
– Collaterals: valgus or varus force
– ACL: plant and twist, hyperextension or quick
deceleration
– PCL: direct anterior force on bent knee
(dashboard injury or fall onto tibia of flexed knee)
• May have heard/felt a pop
• ACL: immediate large swelling
• Feeling of instability
MCL/LCL: Physical Exam
• LOOK – soft-tissue swelling
• FEEL - tenderness over ligament
• TEST- at 0 and 20 degrees-test for pain and laxity to
differentiate grade of injury
PCL: Physical Exam
• Mild to moderate effusion
• May not have any palpable
tenderness but can feel step-off
• Posterior Sag/Posterior drawer
test
PCL: Posterior Sag
PCL: Posterior Drawer
ACL Physical Exam:
• Hemarthrosis: large effusion (patellar tap)
• May have associated meniscal or MCL tear
• Can have avulsion fracture lateral tibial plateau so
tenderness there common
• Lachman (15-30o flexion) most sensitive and specific
knee test, Anterior Drawer, Pivot Shift (if MCL intact
and no meniscus tear)
 Anterior drawer: Sens 48% Spec 87%
 Pivot shift: Sens 61% Spec 97% (but only studied by its
developers)
 Lachman’s: Sens 87% Spec 93%, LR+ 42.0
ACL: Lachman’s
Practice
• Lachman’s (or Drop Leg Lachman’s)
• MCL & LCL Collateral tests (at 0 and 20)
• Posterior Drawer
Patella: Anatomy
Patella: History
• Anterior knee pain
• Often worse going down stairs, squatting,
kneeling
• Sometimes pain will cause quads inhibitionpatients get giving way
Patella: Physical Exam
• Look for contributing biomechanical factors: genu
valgus, femoral anteversion, pes
planus/overpronation
• Tender patella facettes, retropatellar crepitus
• J-sign
• Assess patella: Laxity/apprehension,
compression/Osmond-Clark
• Assess for correctable factors:
– Tightness: hamstrings, IT Band (Ober’s)
– Strength: VMO, abductors
Patella: Obers
Practice
•
•
•
•
•
•
Palpation of patellar facets
J-sign
Laxity/apprehension
Compression test
Ober’s
Hip Abductor strength
HIP ASSESSMENT
HISTORY
Chief Complaint:
Mechanism of injury:
Duration:
Location:
Lateral
Anterior
Other - “C” SIGN
Radiation:
Groin
Buttocks
Thigh
Other
Severity when most severe: (0 to 10)
Catching:
When does pain occur? (rest; sitting; walk; run; stairs up/down; uneven
ground; in/out car; during activity; after activity; morning; afternoon; night;
other relation to bowel bladder, menses):
Relieving Factors:
Treatment to date:
Past history of knee injury or related hx:
Other medical history:
Medication:
Allergies:
Hip: Location of Pain
HIP: PHYSICAL EXAMINATION
LOOK
FEEL
MOVE
SPECIAL TESTS
LOOK
Standing: Alignment
Walking:
Antalgic favours: Right
Trendelenburg
PWB
NWB
AIDS: crutches/cane/w/c
Left
LOOK
Lying:
Swelling
Muscle wasting
Flexion deformity
Position
FEEL
Palpate points of maximal tenderness:
Bones: ASIS, Greater trochanter and bursa, Pubic ramus
and symphysis, Ischial tuberosity, SI joints
Muscles & Tendons: Adductors, IT band (TFL), gluteus
minimus/maximus, piriformis, Hamstring
Abdomen and Lumbar Spine if indicated
Hip bones
Hip Muscles
“Glutes” and GT Bursae
Piriformis
Glut Medius
Glut Minimus
Glut Maximus
GT Bursa of Glut Medius
GT Bursa of Glut Maximus
Practice
• Bones:
– Greater trochanter
– Pubic Symphysis
– Anterior Inferior and Superior Iliac Spine
– Ischial tuberosity
– SI joints
• Muscles:
– Piriformis
MOVE
Hip Range of Motion:
Active Passive
Flexion: (~120°)
Extension: (~20-30°)
Abduction: (~45-50°)
Adduction: (~20°)
Internal rotation: (~35°)
External rotation: (~45°)
Resisted
Special Tests
FAI or FADDIR testing: labrum/joint
Trendelenburg test: abductor strength
Thomas test (flexion contracture/ITB tightness)
FABER: Pain (groin, lateral, SI)
Functional tests:
Hop on Rt and Lt (pain?)
Flexion-adduction-internal rotation
test (FAI)
Trendelenburg test
Thomas test
FABER
Back: Special Tests
• Back ROM:
Flexion
Extension
Lateral flexion
• Sacro-iliac Kinetic Test
• Leg Lengths: Rt_____cm.
Lt_____cm.
Rotation
Practice
Passive IR
FAI test
Trendelenburg test
Thomas test
FABER
Thank You!