examination and imaging of the kneeforms.acsm.org/15tpc/pdfs/17 johnson a.pdf · • fracture 1-...

San Antonio Military Medical Center

The warrior above all others prays for peace for it is the warrior above all others who must suffer and bear the deepest wounds and scars of warrdquo

LTC ANTHONY E JOHNSON MD FAAOS CHAIRMAN DEPARTMENT OF ORTHOPAEDICS amp REHABILITATION

CO-CHAIRMAN US ARMED FORCES SPORTS MEDICAL ADVISORY GROUP TEAM PHYSICIAN USA PARALYMPIC BASKETBALL

ACSM Team Physician Course 6 February 2015

Examination and Imaging of the Knee



Focused History Questions

bull Onset of Pain ndash Date of injury or when symptoms started

bull Location of Pain ndash Anterior ndash Medial ndash Lateral ndash Posterior

bull Injury-Associated Events ndash Pop heard or felt ndash Swelling after injury (immediate vs delayed) ndash Catching Locking ndash Buckling Instability (ldquogiving wayrdquo)




bull Degree of Immediate Dysfunction

|------------------------| Unable to Antalgic Continued Ambulate Gait to Participate

bull Aggravating Factors ndash Activities changing positions stairs kneeling

bull Relieving Factorstreatments tried ndash Ice medications crutches

bull History of previous knee injury or surgery



Historical Clues to Knee Injury Diagnoses

Noncontact injury with ldquopoprdquo ACL tear Contact injury with ldquopoprdquo MCL or LCL tear meniscus

tear fracture Acute swelling ACL tear PCL tear fracture

knee dislocation patellar dislocation

Lateral blow to the knee MCL tear Medial blow to the knee LCL tear Knee ldquogave outrdquo or ldquobuckledrdquo ACL tear patellar dislocation Fall onto a flexed knee PCL tear



Differential Diagnosis of Knee Hemarthrosis

bull ACL 65 - 70 bull Meniscus 125 - 50 bull Fracture 1- 20 bull Patellar dislocation 11 - 20 bull w Osteochondral lesion 5 bull PCL 1-5

Benedetto KP Knee joint hemarthrosis--differential diagnostic considerations for planning an operation Orthopade 1990 Apr19(2)69-76



Observe ndash Static Alignment

bull Medial aspects of knees and ankles in contact

httpwwworthoseekcomarticlesimgbowl1gif

Genu valgum Genu varum





Ottawa Knee Rules

bull When to order a knee x-ray after acute injury ndash Age gt 55 or lt 18 ndash Unable to walk ndash TTP on PATELLA ndash TTP on FIBULAR HEAD ndash Unable to flex 90 deg

bull 100 sensitive ndash Reduced radiographs by 49

Emparanza JI Validation of the Ottawa Knee Rules Ann Emerg Med 2001 Oct38(4)364-8



Patellofemoral Joint Exam



Patellar Tilt nl is 15deg

Patellar Slide normal is 25-50

Patellar Apprehension w lateral movement



Patellar dislocationsubluxation

bull Mechanism of injury ndash Direct trauma ndash Rotation over planted

foot (ie softball swing) ndash Sudden cutting

movements ndash Prior injury predispose

for recurrence



Patellar dislocationinstability

bull Imaging ndash Standard knee x-rays a

good start ndash MRI to ro associated

injuries bull Hemearthrosis



13

Valgus Stress Test for MCL

Note Direction Of Forces



Location MCL Tissue Damage

bull Proximal ruptures heal more quickly ndash But have more stiffness

bull Complete ruptures can displace into the joint

bull Damage over entire ligament associated with persistent laxity after non-operative treatment

Nakamura N (2003) Acute grade III MCL injury of the knee associated with ACL tear usefulness of MRI in determining treatment regimenrdquo Am J Sports Med 31(2) 261-7



Collegiate Football Severity vs Return

bull Grade I ndash 106 days bull Grade II ndash 195 days

Derscheid GL and JG Garrick Am J Sports Med 1981 9(6) p 365-8



Varus Stress Test for LCL Note Direction Of Forces



17

Lachman Test

Note direction of forces



18

Anterior Drawer Test for ACL




Review of Evidence ndash ACL

bull Lachman Test Sens 87 Spec 93 bull Anterior Drawer Sens 48 Spec 87 bull Pivot Shift Test Sens 61 Spec 97

Jackson JL OrsquoMalley PG Kroenke K Evaluation of Acute Knee Pain in Primary Care Ann Intern Med 2003139575-588



Sex Issues Related to ACL Injuries

bull Females more likely to sustain an ACL injury than males ndash Soccer - 26X ndash Basketball - 575X

bull Wider pelvis bull Greater flexibility bull Less-developed musculature bull Hypoplastic vastus medialis oblique bull Narrow femoral notch bull Genu valgum bull External tibial torsion



ACL Radiographic Findings

bull Segond fracture ndash Avulsion of the lateral

capsular ligament)




bull Avulsion of the intercondylar tubercle



Review of Evidence - Meniscus

bull Joint Line Tenderness Sens 76 Spec 29 bull McMurray Test Sens 52 Spec 97 Jackson JL OrsquoMalley PG Kroenke K Evaluation of Acute Knee Pain in Primary Care Ann Intern Med 2003139575-588



Posterior Drawer Test - PCL




External Rotation Dial Test - (PLC)

Symmetric = NORMAL Asymmetric = ABNORMAL



Flexibility

Popliteal Angle Thomas Test



Iliotibial Band Sydrome

Clinical symptoms bull Lateral knee pain bull Associated with hills

and banked surfaces bull Common running injury



bull Noblersquos test ndash Palpate lateral femoral

condyle ndash Flex and Extend Knee ndash + Test is pain at site of

palpation



Extensor Mechanism Injuries I



Extensor Tendon Injuries II



Extensor Tendon Injuries III



Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10






Varus Stress Test for LCL

Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34




bull Onset of Pain ndash Date of injury or when symptoms started

bull Location of Pain ndash Anterior ndash Medial ndash Lateral ndash Posterior

bull Injury-Associated Events ndash Pop heard or felt ndash Swelling after injury (immediate vs delayed) ndash Catching Locking ndash Buckling Instability (ldquogiving wayrdquo)































Ottawa Knee Rules


















for recurrence









13




















17

Lachman Test




18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34































Ottawa Knee Rules


















for recurrence









13




















17

Lachman Test




18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34















for recurrence









13




















17

Lachman Test




18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34









13




















17

Lachman Test




18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34


















17

Lachman Test




18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34



18

















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34















capsular ligament)



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34



















Flexibility











palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34










palpation












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34












Osgood-Schlatter





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34





Slide Number 1






Slide Number 7

Ottawa Knee Rules


Slide Number 10







Lachman Test









Flexibility


Slide Number 28




Osgood-Schlatter

Slide Number 34

examination and imaging of the kneeforms.acsm.org/15tpc/pdfs/17 johnson a.pdf · • fracture 1-...

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