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Examination of the Knee

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Examination of the Knee 5/25/2016 George J. Davies, DPT, MED, PT, SCS, ATC, LAT, CSCS, NASM-PES, NASM-CES, ACSM-CET, APTA-CCI, SMAC, (REMT), FAPTA Thank You Professor of Physical Therapy, AASU, Savannah, GA. (2004- ) z Thanks to RUSH 2016 SPORTS Professor Emeritus UW-LaCrosse, WI. (1975-2004) Consultant, Clinician, Co-Director Clinical and Research Services– MEDICINE SYMPOSIUM for the Sports PT Residency Program , GLSM, La Crosse, WI. (1995-present) kind invitation to present at this Sports PT, Coastal Therapy, Savannah, GA. (2004- present) course Past President Sports Physical Therapy Section – APTA (1992-1998) JOSPT - Co-Founder & Co-Editor, 1979 JOSPT - GJD-JAG Excellence in Clinical Research Award, 2004 Fellow, APTA, 2005, Hall of Fame Award, SPTS-APTA, 2006 NATA, President’s Award, 2007, NATA, Most Distinguished Athletic Trainer, 2009 z It is indeed an honor and privilege Sports Health - Co-Founder & Co-Editor, 2009 to be invited to participate and AOSSM – Hall of Fame Award, 2013 share information. Disclosures: Disclosures: The following companies have Disclosures: provided research equipment support to Biodynamics & Human Associate Editor, Performance CenterCenter--AASU:AASU: ArthrometricsArthrometrics,, Atlanta, GA. Sports Health Editor Biodex, Shirley, N.Y. PUBMED CDM Sport/Monitored Rehab Elsevier-Book Royalties Systems, Fort Worth , TX. INDEX MEDICUS Human KineticsKinetics--BookBook Royalties ElsevierElsevier-- DS2 Rehab Systems, Missouri City, 2015 Williams & Wilkins-Wilkins-BookBook Royalties Book Royalties TX North American SeminarsSeminars--DVDDVD ERMI, Atlanta, GA. Royalties ExerToolsExerTools,, Petaluma, CA. Innovative Sports Inc, Chicago, IL. Conflicts TheraBandTheraBand,, Hygenic Corporation, No Conflicts Akron, OH. No Conflicts 2015 Disclosures: Casual interest in the “Gladly accept knee money from Examination anyone for for the last Institutional 51 years since I Research of the Support….” started as a student Knee athletic trainer in 1965 !!! No Conflicts 1 5/25/2016 Examination of the Knee Examination of z This is an article that we published the Knee: 38 years ago in the Physician and SportsMedicine that was used for CME’ s for physicians. How do we do z At that time it was ““statestate of the artart”,”, and it’s interesting how much it? of that that art has stayed the same, with of course, some changes! P & SM, 1978 Subjective Examination Knee Subjective, and History of the Knee Mechanism of Injury Complex Objective & Functional Examination Subjective Exam Subjective Differential Diagnosis Components Exam Components z Diagnostic tests & Imaging Studies z Demographic information z Lab tests z Location of symptoms z DiDominan t arm z Medical systems review: questionnaire Systems review z MOI and interview (Differential DX.) and differential z History: present & past z Meds z Previous treatments z Behavior of symptoms: rest, ADL’s, diagnosis work, sports, AM/PM z Previous functional status z Patient’s goals 2 5/25/2016 Functional Testing Algorithm – Functional Testing Algorithm FTA Specific Guidelines Knee -2016 kSports Specific Tests z LEFT ––MM--1:30;1:30; FF--2:002:00 minutes z Sport Specific Testing Competitive kLower Extremity Functional Tests z HOP - < 10%Ht.; < 10% bilat.bilat. Comp.; z Lower Extremity Functional Norms/various hops Athletes kFunctional Hop Tests Tests z JUMP - < 15%/Ht.; Norms z Functional Hop Tests kFunctional Jump Tests z OKC Isokinetics - < 25% bilateral z Functional Jump Tests Recreational kOKC Isokinetic Tests comparison/other criteria z OKC Isokinetic testing Athletes kCKC Isokinetic Tests z CKC Isokinetics - < 30% bilateral comparison z CKC Isokinetic Testing kKinesthetic/Balance Tests z Sensorimotor System Testing: General z Kinesthetic/Balance Testing – Bilat Balance/Proprioceptive Orthopaedic kKT 1000 Tests comp Testing Patients kSpecial Tests – ONLY 175 + 1 z KT 1000 - < 3 mm bilateral comparison z KT 1000/2000 kBasic Measurements z Basic Measurements - < 10% bilateral z Basic Measurements comparison Basic Measurements Basic Measurements zTime/soft tissue healing z MD Clearance & Approval zVAS (0(0--1010 scale) z Time/soft tissue healing zAnthropometric z VAS (0(0--1010 scale) measurements z Anthropometric measurements zAROM, PROM z AROM, PROM z Special Tests zSpecial Tests z Qualitative & Quantitative zQualitative & Quantitative Movement Assessment Movement Assessment z Knee Rating scales: IKDC, etc. zKnee Rating scales: IKDC, etc. Functional Testing Algorithm ACL Quad Tendon Dark Quad We still have not Tendon PrePre-- Graft Healing answered this Question? TIME: Op Soft tissue healing from zBiologics and “mother nature” the inj ury or anddth the: from a zNeoangiogenesis zMaturation post-surgical condition Time Zero 1 month PO 6 months PO zLigamentization 3 5/25/2016 Functional Testing Algorithm Clinical Decision Making Clinical Decision Making TIME: Soft tissue healing We need similar types of outcomes regarding the biology of healing We can’t hurry “mother nature”; Although we are trying with all the biologics!!! Clinical Decision Making Clinical Decision Making Basic Measurements zPerhaps wait for 3-6 z Hamstrings more months to allow Time/soft the biologics to “do their job”…. tissue BTB healing ACL Quad Tendon Dark Quad Clinical Decision Making Tendon PrePre-- Graft Healing Op Then we return him back to sports Time Zero 1 month PO 6 months PO 1 year PO 4 5/25/2016 Physical Examination/ Physical Examination of the Physical Tests & Measurements Knee z Observation/ z Physiological PROM posture z Gait Evaluation z Accessory/Jt. Play 1) Most physical exam tests should PROM Q & Q Movement be referenced back to the original ((ObjectiveObjective)) z KT 1000 Assessment z Flexibility Tests description z Referral/related joints z RROM (MMT/HHD) z 2) Sensitivity z Neurological Exam z Special Tests EitiExamination z Computerized z Sensation, reflexes z 3) Specificity isokinetic testing z Kinesthetic/ proprioceptive z Functional Testing z 4) Likelihood ratios z Imaging Studies Balance z 5) PPV of the Knee z Lab Studies Neural TT z Palpation z 6) NPV z AROM Functional Testing Algorithm – Functional Testing Algorithm – Functional Testing Algorithm – Knee -2016 Knee Knee z Progression to the next higher level of z Sport Specific Testing Competitive zObjective, quantitative (and z Lower Extremity Functional Athletes qualitative), systematic testing difficulty is predicated upon Tests passing the prior test in the series… z Functional Hop Tests testing and rehabilitation z Functional Jump Tests Recreational method to safely and rapidly z Each successive test and its associated z OKC Isokinetic testing Athletes progress a patient from training regimen places increasing z CKC Isokinetic Testing stress on the patient while at the same General immediate post injury/post-injury/post- z Sensorimotor System Testing: time decreasing clinical control Balance/Proprioceptive Orthopaedic op to return to full functional Testing Patients z KT 1000/2000 activities and return to play in z So how does it really work? z Basic Measurements sports DC to Focused Within NOT Sports Functional Testing Algorithm – 30%30%--YESYES Within RehabRehab-- CKC 30% NOT Focused Knee Exercises Within Within Specificity 10%10%--YESYES CKC Power Norms Rehab zWe can rehabilitate patients Testing Specificity NOT Focused Testing faster than ever because by Within Within Focused RehabRehab-- NOT 10%10%--YESYES 10% Within RehabRehab-- testing themthem, we always know Balance Within NormsNorms-- Functional YES Norms Jump/Jump/HopHop whthtitiithhere the patient is in the SensoriSensori-- Exercises motor Functional rehab program and can focus testing Testing NOT Within the interventions specifically on Within Focused NOT Focused 10%10%--YESYES Rehab Within 25%25%-- Within 10% YES RehabRehab-- the patient’s particular 25% OKC Basic Exercises condition and status MeasureMeasure-- OKC ments Testing 5 5/25/2016 Physical Examination/ Tests & Measurements KT 1000 Tests z Observation/ posture z Physiological PROM Gait Evaluation z Accessory/Jt. Play PROM Q & Q Movement Assessment z KT 1000 Observation z Flexibility Tests z Referral/related joints z RROM (MMT/HHD) z Neurological Exam z Special Tests z Sensation, reflexes z Computerized & Posture isokinetic testing z Kinesthetic/ proprioceptive z Functional Testing Balance z Imaging Studies Neural TT z Lab Studies z Palpation z AROM Gait Evaluation Q & Q Movement AtAssessment Qualitative Movement Analysis of the Entire Kinematic Chain in all Planes of Motion Regional Interdependency Basic Measurements Performance Tests z Qualitative & Quantitative Single Leg Step TOTAL BODY INTERDEPENDENCY Movement Assessment: Down Analysis If movement is one integrated z Step Down Tests: pattern, regardless of its complexity, then we must evaluate and treat z The TOTAL PATIENT 6 5/25/2016 Axial Spinal “Clearing” Appendicular Peripheral Joint “Clearing” Tests Tests • Lumbar Spine Hip • AROM • PROM – End ROM • MMT – Mid ROM Proximal Tib-Fib Joint • Special Tests Ankle • SI Joint Foot Neurological Exam-Exam-SensorimotorSensorimotor System Testing Knee Kinesthetic Testing •Balance •Sensation – dermatomes etc. •Balance •Reflexes •Angular Joint Replication •Neurodynamic testing •End ROM Reproduction •MMT •Threshold to Sensation of •Kinesthesia/Proprioception Movement Biodex Clinical Balance It has been my clinical Biomechanics Stabilometer 17:55117:551--554,554, observation (performance 2002 motion assessment) that after a LE injury, individuals do not bear weight equally during double-double-legleg exercises, especially on
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