the examination of the knee · · 2018-04-11the examination of the knee echo sports medicine...
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THE EXAMINATION OF THE KNEEECHO SPORTS MEDICINE 4/7/2016
Author:Ali Shahin, M.D. 03.30.2011
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Objective
Learn how to do a quick and thorough knee exam Be able to identify
Collateral ligament sprains/tears (LCL, MCL) Cruciate ligament sprains/tears (ACL, PCL) Meniscus injuries Patellofemoral syndrome Osteoarthritis Osgood Schlatter Disease Patellar tendinitis Pes anserine bursitis Illiotibial (IT) Band syndrome
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Swelling/effusion, erythema, ecchymosis Knee angle
Genu varum (bowed legs) Genu valgum (can predispose to patellofemoral
syndrome)
Inspection
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Palpate the patient in the sitting position Start with the joint line
Palpation
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Palpation
Joint line tenderness: Meniscal injury Osteoarthritis Fracture
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Next, find the inferior pole of the patella and palpate the patella tendon down to its insertion at the tibial tuberosity
Palpation
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Area of tenderness and probable swelling
Likely causes
Inferior pole of patella Sinding-Larsen-Johansson syndrome
Patellar tendon Patellar tendinopathyPatellar rupture
Patellar insertion at tibial tuberosity Osgood-Schlatter-Disease
Palpation
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When you are at the tibial tuberosity palpate with your finger 1-2 cm medially
If the patient is tender there, consider Pes anserine bursitis
Palpation
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Have the patient lay supine Start with palpating:
Medial and lateral femoral and tibial (epi)condyles & the fibular head:Medial collateral ligament (MCL) sprain Lateral collateral ligament (LCL) sprain Iliotibial (IT) band syndrome Tibial plateau fracture Fibular head fracture
Palpation
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IT-band syndrome
Palpation
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If equivocal, compare with the other knee
Effusion: ‘Milking’ Effusion is assessed by "milking" fluid distally from the
suprapatellar pouch Place one hand on the supra-patellar pouch. Gently push
down and towards the patella, forcing any fluid to accumulate in the central part of the joint
Palpate the area adjacent to the patellar tendon for fluid accumulation
Palpation
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Effusion: Ballottement A ballotable patella may be
palpated after similar effusion milking Place one hand on the supra-
patellar pouch. Gently push down and towards the patella, forcing any fluid to accumulate in the central part of the joint
Gently push down on the patella with your thumb
If there is a sizable effusion, the patella will feel as if it is floating and ‘bounce’ back up when pushed down
Palpation
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Palpation
After a trauma there is effusion (hemarthrosis) only if structures in the joint are involved: Anterior cruciate or posterior cruciate ligament (ACL, PCL) injury Meniscus injury Patellar dislocation Intra-articular fracture (e.g. tibial plateau fracture) Remember: Sole collateral ligament (MCL, LCL) sprains will not
cause an effusion Causes of non-traumatic effusion:
Osteoarthritis, rheumatoid arthritis, gout, pseudo gout, Reiter’s syndrome
Infections e.g. gonorrhea Tumors
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Patellofemoral syndrome (PFPS) The “J” sign The patient supine or
seated and the knee extended from a flexed position. Lateral deviation of the patella can be observed during the terminal phase of extension
Inspection
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Palpation
Next, clinical tests for patellar mobility and position, and provocative tests for pain should be performed:
patellar glide patellar tilt and patellar grind tests Positive results on these tests are consistent with the diagnosis
of PFPS The patellar apprehension test is used to assess for lateral
instability and is positive when pain or discomfort occurs with lateral translation of the patella
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Patellar glide Assesses patellar
mobility Displacement of more
than three quadrants suggests patellar hypermobility caused by poor medial restraints predisposing for PFPS
Also, palpate the medial & lateral undersurface of the patella
Palpation
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Patellar tilt Positive test = lateral
aspect of patella is fixed and cannot be raised to at least horizontal position
Indicates tight lateral structures (e.g.: IT-band) predisposing for PFPS
Palpation
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Patellar grind test The patient is in the supine
position with the knee extended The examiner displaces the
patella inferiorly into the trochlear groove
The patient is then asked to contract the quadriceps while the examiner continues to palpate the patella and provides gentle resistance to superior movement of the patella
The test is indicative of PFPS if pain is produced
Palpation
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Apprehension test
Patient is apprehensive if the examiner tries to move the patella laterally
Positive after patellar (sub)luxation and in severe PFPS
Palpation
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Range Of Motion (ROM)
Test for active & passive ROM while the patient is supine Flexion 140° Extension 0° /-10° Internal rotation 10° External rotation 10°
Always compare to the other, “healthy” knee!
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Apply valgus stress with the knee at 0° and bent at 30° 0° tests for MCL as well as the
cruciate ligaments 30° only tests the MCL
Pain speaks for mild sprain Pain & laxity speak for
moderate sprain No fix endpoint speaks for
complete MCL rupture
Special Tests: MCL
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Apply varus stress with the knee at 0° and bent at 30° 0° tests for LCL as well as the
cruciate ligaments 30° only tests the LCL
Pain speaks for mild sprain Pain & laxity speak for
moderate sprain No fix endpoint speaks for
complete LCL rupture
Special Tests: LCL
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Lachman test Patient supine with knee flexed
30° Pull on the tibia towards you
Anterior drawer test Patient supine with knee flexed
90° Stabilize patient’s foot by sitting
on it Cup your hands around patient’s
knee & draw the tibia towards you
Special Tests: ACL
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Lachman & anterior drawer test are positive if There is increased amount of anterior tibial translation
compared with the opposite leg, and/or There is no firm end-point
Special Tests: ACL
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[1] Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006 May;36(5):267-88.
[2] Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res. 1995 Aug;(317):237-42.
Sensitivity Specificity
Lachman test 85%[1] 94%[1]
Anterior Drawer test 68%[2] 79%[2]
Pivot Shift test 24%[1] 98%[1]
Special Tests: ACL
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Posterior drawer test Stay in the same position as for
the anterior drawer test Push the tibia posteriorly If it moves backwards the PCL is
probably damaged
Special Tests: PCL
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Another way of testing the PCL is the sag sign
Special Tests: PCL
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Sag sign
Special Tests: PCL
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Mc Murray Hold the knee with one hand, place your fingers along
the joint line and flex it to 90° Hold the foot by the sole with the other hand
Special Tests: Meniscus
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Mc Murray (cont) Provide a valgus stress Rotate the leg externally Extend the knee If pain or a ‘click’ is felt = ‘positive McMurray’ for a medial
meniscus tear
Special Tests: Meniscus
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Mc Murray (cont) Provide a varus stress Rotate the leg internally Extend the knee If pain or a ‘click’ is felt = ‘positive McMurray’ for a lateral
meniscus tear
Special Tests: Meniscus
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Apley grind test The patient lays prone and flexes his/her knee 90° Place your hand on the patient’s heel and push down (to
compress the menisci between femur & tibia) while rotating internally & externally
Depending on the area of pain medial or lateral meniscus tear
Special Tests: Meniscus
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Ober’s Test The patient lies with the unaffected side down and the
unaffected hip and knee at a 90-degree angle. If the IT-band is tight, the patient will have difficulty adducting the leg beyond the midline and may experience pain at the lateral knee
Special Tests: IT-band Syndrome
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Referred pain
‘Knee pain’ can be referred from the lumbar spine (e.g. herniated disk) or from a hip or ankle pathology, so don’t forget to Do a gross hip and ankle exam Test the motor strength, sensibility and deep tendon
reflexes of the lower extremities
And always examine both knees!
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References
Various articles from American Family Physician(www.aafp.org)
Hoppenfeld Physical Examination of the Spine & Extremities
Netter’s Sports Medicine