Transcript Knee Exam

Musculoskeletal
Curriculum
History &
Physical Exam of
the Injured Knee
Copyright 2005
Focused History
Focused History Questions

Onset of Pain


Date of injury or when symptoms started
Location of pain*




Anterior
Medial
Lateral
Posterior
3
Focused History Questions

2
Mechanism of Injury -helps
predict injured structure

Contact or noncontact injury?*


If contact, what part of the knee was
contacted?

Anterior blow?

Valgus force?

Varus force?
Was foot of affected knee planted
on the ground?**
Valgus alignment =
distal segment
deviates lateral with
respect to proximal
segment.
Patellas Touch
http://moon.ouhsc.edu/dthompso/namics/varus.gif
4
Focused History Questions

3
Injury-Associated Events*

Pop heard or felt?

Swelling after injury (immediate vs delayed)

Catching / Locking

Buckling / Instability (“giving way”)
5
Instability - Example
Patellar dislocation
http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocat
ion.JPG
6
Focused History Questions
 Degree
4
of Immediate Dysfunction
|------------------------|
Unable to
Ambulate
Antalgic
Gait*
Continued
to Participate
7
Focused History Questions

Aggravating Factors


Activities, changing positions, stairs, kneeling
Relieving Factors/treatments tried


5
Ice, medications, crutches
History of previous knee injury or surgery
8
Physical Exam
Physical Exam - General


Develop a standard routine*
Alleviate the patient's fears
GENERAL STEPS
Inspection
Palpation
Range of motion
Strength testing
Special tests
10
Physical Exam - Exposure



Adequate exposure - groin to
toes bilaterally
Examine in supine position
Compare knees
11
Observe – Static Alignment
Patient stands facing examiner with
feet shoulder width apart



Ankles, subtalar joints – pronation, supination
Feet – pes planus, pes cavus
Pes planus
(http://www.steenwyk.com/pronsup.htm)
Pes cavus
(http://www.arc.org.uk/about_arth/booklets/6012/images/6012_1.gif)
12
Observe – Static Alignment

Patient then
brings medial
aspects of knees
and ankles in
contact

Knees – genu valgum
(I), genu varum (II)
Genu valgum
Genu varum
(http://www.orthoseek.com/articles/img/bowl1.gif)
13
Inspect Knee
 Evidence
of
local trauma
Abrasions
 Contusions
 Lacerations




Warmth
Erythema
Effusion*
 Patella
position
 Muscle atrophy
14
Inspect Knee-Related Muscles
Quadriceps atrophy


Long-standing problem
Vastus medialis
atrophy


After surgery
http://www.neuro.wustl.edu/neuromuscular/pics/people/patients/Hands/ibmquadatrsm.jpg
15
Normal Knee – Anterior, Extended
16
Surface Anatomy - Anterior, Extended*
Patella
Indented
Hollow
17
Normal Knee – Anterior, Flexed
18
Surface Anatomy - Anterior, Flexed
Patella
Tibial
Tuberosity
Head
Of
Fibula
19
Palpation – Anterior*
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar Facets
Medial Fat
Pat
Lateral Fat Pad
Patellar Tendon**
20
Surface Anatomy - Medial
Tibial
Tuberosity
Joint
Line
Patella
Medial
Femoral
Condyle
Medial
Tibial
Condyle
21
Palpation - Medial
Medial Collateral Ligament (MCL)*
Pes anserine
bursa**
Medial joint
line
22
Surface Anatomy – Lateral
Quadriceps
Patella
Tibial
Tuberosity
Head
Of
Fibula
23
Palpation – Lateral*
Lateral Collateral
Ligament (LCL)**
Lateral joint
line
24
Palpation - Posterior

Popliteal fossa*

Abnormal bulges



Popliteal artery aneurysm
Popliteal thrombophlebitis
Baker’s cyst
25
Range Of Motion Testing

Extension
0º

Describe loss of degrees of extension


Flexion
135º
Example: “lacks 5 degrees of
extension”
Locking* = patient unable to fully extend or flex
knee due to a mechanical blockage in the knee
(i.e., loose body, bucket-handle meniscus tear)
26
Strength Testing

Test knee extensors (quadriceps) and knee
flexors (hamstrings)




Can test both with patient in seated position,
knees bent over edge of table
Ask patient to extend/straighten knee against your
resistance
Then ask patient to flex/bend knee against your
resistance
Compare to unaffected knee
27
Special Tests – Anterior Knee Pain

Patellar apprehension test*
Starting
position
Push patella
laterally
(http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lateral%20patellar%20
apprehension.htm)

Patellofemoral grind test**
28
Special Tests - Ligaments
Anterior Cruciate

Posterior
Cruciate
Assess stability
of 4 knee
ligaments via
applied
stresses*
Medial Collateral
Lateral Collateral
29
Stress Testing of Ligaments
Use a standard exam routine




1.
Direct, gentle pressure
No sudden forces
Abnormal test
Excessive motion = laxity
What is NORMAL motion?*
2.
Soft/mushy end point**
30
Collateral Ligament Assessment
Patient and Examiner
Position*
31
Valgus Stress Test for MCL*
Note Direction Of Forces
32
Varus Stress Test for LCL*
Note direction of forces
33
Lachman Test*


Patient Position
Physician hand placement
34
Lachman Test2

View from lateral aspect*
Note direction of forces
35
Anterior Drawer Test for ACL


Physician Position & Movements*
Patient Position
Note direction of forces
36
Posterior Drawer Testing- PCL*
Note direction of forces
37
Assess Meniscus – Knee Flexion

Most sensitive test is full flexion*


Examiner passively flexes the knee or has patient
perform a full two-legged squat to test for
meniscal injury
Joint line tenderness**

Flexion of the knee enhances palpation of the
anterior half of each meniscus
38
Review of Evidence – ACL*
(Jackson JL, et al.)



Lachman Test
Anterior Drawer
Pivot Shift Test
Sens 87% Spec 93%
Sens 48% Spec 87%
Sens 61% Spec 97%
39
Review of Evidence - Meniscus
(Jackson JL, et al.)


Joint Line Tenderness
McMurray Test
Sens 76% Spec 29%
Sens 52% Spec 97%
40
Video of Knee Exam
http://www.fammed.wisc.edu/knee-exam/
41