Transcript Knee Examination

Knee Examination
Alireza Moghtaderi,MD
Assistant Professor of Physical Medicine and Rehabilitation
Isfahan University of Medical sciences
Knee
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The largest joint,,,,,,
Connecting two major bone,,,,,,
More than just a simple Hinge,,,,
Patella is the Largest Sesamoid
Visual examination,,,,,
Unstable joint,,,,,
Patella acts as a Fulcrum,,,,,
Anatomy
Bursa
Physical exam:
Look
Feel
Move
Special tests
Look (always compare)
Alignment ( normal, varus or valgus)
Effusion
Scars
Wasting
Color
Feel
Temperature (compare)
Tenderness ( feel the bony prominences)
Effusion (fluid collection)
* fluctuation
* bulging (milking)
* ballotment (patellar tapping)
Move
Active ( by the patient)
Passive ( by the physician)
Special tests
Meniscus
Stability
Patella
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Normally,only a thin layer of
tendon,bursa and subcutaneous tissue
lies between the patella and the skin..
Even in obese patient ,subcutaneous fat
tends to be relatively sparse over the
patella. In such patient ,the patella often
appears as a depression amid the
billows of the surrounding limb…
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The patella normally appears oval
Bipartite Patella (This is manifested as a protruding
prominence at the supralateral aspect of the patella)
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Patella Magna
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Patella Alta
Patella Baja
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(The accretion of osteophytes around
the edges of the patella can create an enlarged appearance)
(High riding patella)
(Low riding patella)
Bipartite Patella
Patella Magna
Patella Alta
Patella Baja
Patellar Alignment
Squinting Patella
In-Facing,Increased Femoral
Anteversion,Isolated Increase in External
Tibial Torsion,,Duck-Footed
Out Facing Patella
Habitual Subluxation or Dislocation of the
Kneecap
Q Angle
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It is the angle between a line from the
anterior iliac spine to the center of the
patella and line from the center of the
patella through the center of the tibial
tubercle…………………
In averages 15 in normal individuals:
14 in men,,,,17 in women ………
Tubercle Sulcus Angle
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One line is drawn from the center of the
patella through the center of the tibial
tubercle,and another line is drawn from the
center of the patella perpendicular to a line
parallel to the examination table and the
floor …………..
Normally less than 8 in women and 5 in
men……….
Prepatellar Bursa
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A subcutaneous egg-like swelling anterior to
the patella..This swelling is usually fairly soft
and fluid-filled..
If the bursa is infected, the overlying skin is
erythematous and hot
Chronic thickening or nodule formation can
sometimes be seen or palpated in a
prepatellar bursa that has been inflamed in
tha past…
Prepatellar Bursitis
Prepatellar Bursitis
Infrapatellar Bursitis
Patellar Tendon &
Infrapatellar Fat Pad
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Distal to the patella is the Patellar Tendon or Patellar
ligament,the broad flat band that connects the
patella to the tibia.The infrapatellar fat pad,or
Hoffa’s fat pad,bulges forward on both sides of the
patellar tendon and may obscure it..
Flexing the knee causes the fat pad to retract and
increase the visibility of the patellar tendon…
Ganglion Cysts are occasionally found in or
around the fat pad,where they appear as firm
nodular or multilobulated masses….
Infrapatellar Fat Pad
Proximal Tibia
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Osgood-Schlatter disease,,,
Sinding-Larsen-Johansson disease,,,
Tubercle of Gerdy,,,
Medial Tibial Plateau,,,
Pes Anserinus (Gracilis,Semitendinosus,Sartorius),,,
Osgood- Schlatter
Sinding-Larsen-Johansson
syndrome
. Lateral radiograph of
the left knee shows a
tiny avulsed fracture
fragment (arrow)
arising from the
inferior aspect of the
patella.
Medial epicondyle
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Much less prominent than tha patella,the
Medial epicondyle is,nevertheless,often
detectable in the normal knee…
The insertion of the adductor muscles
terminates at the superior portion of this
prominence;The term Adductor tubercle is
thus often used interchangeably with the
term medial epicondyle….
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Because it is the proximal attachment of the MCL,the
prominence of the Medial epicondyl may be increased in the
face of sprains involving the proximal fibers of this ligament..
In Acute case,the increased prominence may be due to
localized hemorrhage and edema.
In the Chronic case,a calcific deposite may form;this
occurrence is identified radiographically as the PelligriniStieda Sign…
On physical examination ,this existence of this calcification
may manifest itself as an enlargement of the prominence of the
Medial epicondyle…
Pelligrini-Stieda
Popliteal cyst
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A popliteal cyst,or Baker’s cyst,is a well known knee
phenomenon. This swellings may be isolated anomalies in
children, but in adults they are usually secondary to
intraarticular pathology,such as a meniscus tear or arthritis.
They are not always visible……..
When they are ,they may appear as a generalized fullness of
the popliteal fossa or a small spherical mass.
They are best seen with the patient prone and relaxed..Smaller
cysts may be palpable but not visible and are most likely to be
located toward the medial side of the Popliteal fossa……..
Synovial sarcoma mimicking popliteal
cyst. In contrast, MR image of knee in
3-year-old boy with palpable popliteal
mass shows sharply circumscribed
lobular lesion (arrow) within popliteal
fossa insinuating between
semimembranosus muscle and medial
head of gastrocnemius muscle that is
bright on T2-weighted image and
enhances peripherally after contrast
administration with no central
enhancement . This lesion is popliteal
cyst..
Standing Limb Alignment
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When ideal alignment is present,the patient is able
to stand with the knees and feet touching
simultaneously……
The allow this to occur, the femur and the tibia must
actually be in mild valgus because the hip joints are
farther part than the knees……
This relationship is known as Physiologic Valgus
Alignment and averages about “7” in women and
“5” in men when measured on a radiograph……
Genu Valgum
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Possible causes are
congenital or
developmental
variations,angular
deformity following a
fracture of the femur or the
tibia,or arthritic erosion and
collaps of the lateral
compartment of the knee…
Genu Varum
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Abnormal varus alignment is more
common than pathologic valgus
alignment..
Possible causes include
congenital or developmental
abnormalities,angular deformity
from old fractures,Severe lateral
ligament injuries,and arthritic
erosion and collapse of the medial
compartment of the knee….
Stability
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To test the four ligaments of the knee:
 ACL (Anterior Cruciate Ligament)
 PCL (Posterior Cruciate Ligament)
 MCL (Medial Collateral Ligament)
 LCL (Lateral Collateral Ligament)
Anterior Drawer Test for ACL
ACL exam
Anterior drawer
test:
Excessive
forward
movement of the
tibia on the
femur
Anterior drawer test:
ACL exam
Pivot shift test:
When positive, it is painful
It needs experience to be able
to elicit it
ACL exam
Lachman’s test :
The most specific
test for ACL rupture
Lachman-Trillat test
For the test, the knee is unlocked in 20°
flexion. The patient's heel rests on the
couch. The examiner holds the patient's
tibia, with the thumb on the tibial
tubercle. The examiner's other hand is
placed on the patient's thigh, a few
centimetres above the patella. The hand
on the tibia applies a brisk anteriorly
directed force to the tibia
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Lachman-Trillat test
Posterior Drawer Testing- PCL
PCL exam
Posterior drawer test :
excessive backward
movement of the tibia in
relation to the femur.
Posterior drawer test
PCL exam
Sagging sign: compare both
knees in 90 degrees of flexion.
In the injured knee the proximal tibia is
displaced backwards compared to the
other side.
Sagging Sign
Godfrey's drop back test
The patient is supine, with the
thighs and knees flexed 90°,
legs horizontal, and heels
held by the examiner in such
a way as to have the legs
parallel to the table. The test
is positive if the upper end of
the tibia on the affected side
is seen to drop backwards
Grading Posterior Laxity
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Normally,the anterior cortex of the proximal tibia
sits about 10 mm anterior to the distal end of the
femoral condyles when the knee is flexed about 90
Grade1,,Grade2,,Grade3 and Grade4
Stability
MCL : Valgus stress test
LCL : Varus stress test
Valgus Stress Test for MCL
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Increased laxity to valgus stress with the knee is full
extension signifies damage not only to the
superficial and the deep MCL fibers but also to the
posteromedial capsule. In such a knee,the
incidence of concomitant injury to one or both
cruciate ligaments is extremely high….
The combination of normal valgus stability when the
knee is fully extended and abnormally increased
valgus laxity when the knee is flexed suggests more
isolated damage to the MCL with an intact
posteromedial capsule….
Varus Stress Test for LCL
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The major difference between thw varus and the
valgus stress tests is that most patients have more
natural laxity of the lateral ligaments than the medial
ligaments.
This separation is probably about 3mm to 5mm in
the average normal knee.
As in the valgus stress test,increased varus laxity in
full extension implies more extensive injury,usually
involving the posterolateral ligament complex and
one or both cruciate ligaments……
Meniscal exam
Tenderness in the medial joint line (medial meniscus)
Tenderness in the lateral joint line (lateral meniscus)
McMurrey’s test for medial and lateral meniscus:
McMurray's Test: Assessment Of
Medial Meniscus
McMurray's Test: Assessment Of
Lateral Meniscus
Chidress’ test
Childress’ Test
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If a meniscus tear is present,this maneuver
usually causes pain localized to the joint
line of the involved meniscus..
In patelofemoral syndrome,the patient
localizes the pain to the retropatellar region.
When an effusion is present in the knee,the
patient usually feels pain or discomfort in
the popliteal fossa during the duck wall..
Apley’s Test
Osteochondritis Dissecans
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For the test,the supine patient is asked to flex the
knee.The examiner then passively internally rotates
the foot and then extends the knee completely.This
maneuver is meant to impinge the ACL against the
classic osteochondritis dessecans lesion located
adjacent to the intercondylar notch on the lateral
aspect of the medial femoral condyle.
In abnormal test,the patient experiences pain when
the internally rotated knee reaches full
extension,and the pain should subside when the
internal rotation force is relaxed……
Thanks