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Physical Examination of Knee Ligament Injuries..Pdf Review Article Physical Examination of Knee Ligament Injuries Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Joseph C. Schaffer, MD A thorough history and physical examination of the knee facilitates accurate diagnosis of ligament injury. Several examination techniques for the knee ligaments that were developed before advanced imaging remain as accurate or more accurate than these newer imaging modalities. Proper use of these examination techniques requires an understanding of the anatomy and pathophysiology of knee ligament injuries. Advanced imaging can be used to augment a history and examination when necessary, but should not replace a thorough history and physical examination. he knee joint is one of the most injuries because the current injury may Tcommonly injured joints in the be the sequela of a previous injury. body. Knee ligament injury and sub- Here, we present specific tech- sequent instability can cause consid- niques for the ligamentous exami- erable disability. Diagnosis of knee nation, including identifying injuries ligament injuries requires a thorough of the anterior cruciate ligament understanding of the anatomy and (ACL), the medial collateral liga- the biomechanics of the joint. Many ment (MCL), the lateral collateral specific examination techniques were ligament (LCL), the posterolateral cor- developed before advanced imaging, ner (PLC), and the posterior cruciate and several techniques remain as ligament (PCL), and describe the asso- accurate or more accurate than the ciated anatomy and biomechanics and From the Division of Sports Medicine, new imaging modalities. Advanced the methods that allow for increased Department of Orthopaedics, University of Rochester School of Medicine and imaging (eg, MRI) is appropriate to diagnostic sensitivity and accuracy. Dentistry, Rochester, NY. use as necessary but should not Neither of the following authors nor replace the history and physical any immediate family member has examination. A survey of patients Anterior Cruciate Ligament received anything of value from or has who obtained a second opinion stock or stock options held in a regarding a knee injury reported that The ACL serves as the primary commercial company or institution related directly or indirectly to the 11% of the previously seen ortho- restraint against anterior tibial trans- subject of this article: Dr. Bronstein paedic surgeons did not palpate the lation in the knee. It also provides and Dr. Schaffer. injured knee and only 37% palpated rotational stability, especially in 1 The video that accompanies this the contralateral knee. extension. The ACL originates on the article is online at http://links.lww.com/ The orthopaedic surgeon should femur at the posteromedial aspect of JAAOS/A30. obtain a thorough history before per- the lateral femoral condyle (postero- J Am Acad Orthop Surg 2017;25: forming a physical examination of the lateral femoral notch) and runs anteri- 280-287 knee. A description of the mechanism orly to its wide tibial insertion at the DOI: 10.5435/JAAOS-D-15-00463 of injury allows the surgeon to assess lateral aspect of the anterior tibial the structures that may have been spine. The ACL has two fiber bundles, Copyright 2017 by the American Academy of Orthopaedic Surgeons. stressed or compressed. The patient the anteromedial and posterolateral should be queried about previous bundles, which provide varying tension 280 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD from flexion through extension. Injury Figure 1 to the knee ligaments is typically the result of a noncontact change in direc- tion or twisting or landing from a jump. The patient often describes a “pop” that is felt or heard at injury, with the appearance of swelling (ie, hemar- throsis) within a few hours. Anterior Drawer Test Clinical instability of the knee asso- ciated with ACL injury was described as early as 1845.2 Historically, the anterior drawer test has been widely used for the diagnosis of ACL rup- tures, but the origin of the test is somewhat obscure. The test has been Arthroscopic images of the medial compartment obtained via a posterolateral traced back to an 1875 thesis by portal placed in an anterior cruciate ligament–deficient cadaver knee during the anterior drawer test. A, The compartment with no application of anterior tibial George Noulis, who was credited translatory force. B, The compartment with application of anterior tibial trans- with describing not only the anterior latory force. The posterior horn of the medial meniscus (white arrow) acts as a drawer test but also a form of what is doorstop, buttressing against the posterior aspect of the medial femoral condyle now known as the Lachman test.3 (black arrow) and preventing anterior translation of the tibia. The anterior drawer test is per- formed with the patient supine, the hip Figure 2 flexed at 45°, and the knee flexed at 90°. The foot is fixed to the table (often by sitting on it), and the clini- cian applies an anterior force to the proximal tibia, palpating the joint line for anterior translation. Increased anterior translation indicates ACL insufficiency. The sensitivity of the anterior drawer test, however, has been reported to be only 50% when performed with the patient under anesthesia because the posterior horn of the medial meniscus may act as Clinical photographs demonstrating hand positioning for the left knee (A) and the a so-called doorstop that prevents right knee (B) during the Lachman test. During the test, one hand stabilizes the anterior translation, even in the femur laterally while the other hand, which is placed medially, translates the tibia. presence of a torn ACL4 (Figure 1). (3) the articulation of the relatively knee positioned between full extension Lachman Test acute convexity of the posterior medial and 15° flexion.5 Currently, the test is The Lachman test, which was initially femoral condyle and the posterior typically done with the knee flexed 20° described by Torg et al,5 is essentially horn of the medial meniscus that to 30°. The examiner places one hand an anterior drawer performed with the buttresses and prevents anterior laterally on the patient’s thigh to sta- knee at 20° to 30° of flexion. It was translation of the tibia. These limita- bilize the femur, while the other hand designed to overcome three identified tions can lead to false-negative find- grasps the proximal and more sub- limitations of the anterior drawer test: ings (See Video, Supplemental Digital cutaneous medial tibia and applies (1) acute effusion that often precludes Content 1, The Anterior Drawer Test, anterior stress (Figure 2). The test is flexion to 90°, (2) protective spasm of http://links.lww.com/JAAOS/A30). In positive in the presence of anterior the hamstring muscles that can prevent contrast, the Lachman test, as origi- translation and a soft or mushy end anterior translation of the tibia, and nally described, was done with the point. When the ACL is intact, the end April 2017, Vol 25, No 4 281 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Physical Examination of Knee Ligament Injuries Figure 3 Figure 4 Clinical photograph demonstrating the authors’ preferred positioning for Clinical photographs demonstrating a positive Lachman examination before (A) a right knee pivot shift test. and after (B) application of anterior translation. point is hard (Figure 3). With the knee tibia) as the knee approaches full hand against the left forearm, which in slight flexion (20° to 30°), the extension, and spontaneous reduction provides slight internal rotation to the hamstring loses mechanical advantage as the knee flexes to 30° to 40°.The leg.Thelefthandisplacedoverthe by simple geometry, and the relatively reduction is achieved by the pull of proximal fibula and valgus force is flat weight-bearing portion of the the iliotibial band as it passes poste- applied to the knee (Figure 4). This medial femoral condyle more easily rior to the axis of the knee.7 technique provides a stable base and glides over the posterior horn of the In the original description of the allows the examiner to slowly flex the medial meniscus. A positive Lachman pivot shift test, the patient is supine knee with great control. test is used to grade an injury as 1 (ie, with the knee extended. It is essential Because the pivot shift test involves anterior translation .1to5mm that the patient is relaxed for this applying a valgus stress to the knee, it compared with the uninjured knee), 2 test.6,8 The examiner grasps the heel is important that testing be limited in (ie, anterior translation 6 to 10 mm with one hand, pointing the foot the setting of a medial injury. The compared with the uninjured knee), or upward or with internal rotation, and change in the mechanics of the knee 3 (ie, anterior translation .10 mm with the other hand placed over the with the loss of the medial hinge may compared with the uninjured knee). fibular head, the examiner applies a affect the reliability of the test, These grades are based on objective valgus force through the knee, which although this phenomenon has not KT-1000 (arthrometer) measurements impinges the subluxated tibial plateau, been studied. The examiner must but can also be clinically estimated. preventing too easy a reduction. While distinguish between a true pivot shift Any difference between the injured the clinician maintains this valgus and a reverse pivot shift, which is seen and uninjured side should raise sus- force and slight internal rotation, the with posterolateral instability in picion for an ACL injury. Further knee is slowly flexed. As it passes 30° which the tibia reduces in extension classification includes a letter grade of to 40° of flexion, the reduction will and subluxates in flexion.
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