sign in sign up
<<
Home , Crepitus, Drawer test, Knee examination, Lachman test, McMurray test, Palpation

A Standardized Approach Basic Approach to the Examination • Inspection • • Strength Testing Bryant Walrod, MD • Assistant Professor – Clinical Department of Family • Special Tests Division of Sports Medicine The Ohio State University Wexner Medical Center

Knee Examination Inspection • It is important to begin with a standardized • Inspect patient sitting with approach to the knee exam so as to not bent. miss anything. ‒ Observe for an obvious dislocation of the patella or • One also needs to ensure adequate knee . exposure • Evaluate for an effusion ‒ Have the patient get into shorts to fully versus a . expose the knee. ‒ It is also important to • Examine sitting up and supine distinguish between intra- articular or extra articular • Compare with contralateral side swelling.

1 Inspection Functional Observation

• Observe also for erythema, induration and rashes. • Observe for a J sign • Inspect for scars • Picture of j sign and ‒ may indicate a previous surgery which will influence your physical exam. • Look also for muscle atrophy of the quadriceps, hamstrings and gastrocnemius.

Functional Observation Observation • Genu varus •

• Observe ambulation ‒ Pronation ‒ Pes planus

• Genu valgus • Femoral anterversion ‒ Antalgic gait ‒ External rotation of leg

2 Observation Palpation • Start with the patient sitting on the table to knees bent to 90o. • Next have the patient stand • Palpate initially for warmth on one leg. • Then palpate specific structures: ‒ Patella tendon origin and its insertion on tibial tuberosity • Observe for valgus deviation ‒ Quadriceps tendon of the knee with single leg ‒ Pes anserine and Iliotibial bursal areas squatting • Gerdy’s tubercle ‒ Medial and lateral joint line: • Assess for joint line tenderness

Palpation Palpation ‒ Medial and lateral femoral condyle • In the supine position: ‒ Medial and lateral tibial plateau • Palpate for intra-articular versus extra- ‒ Proximal and tibial/fibular articular effusion: articulation ‒ Milking test ‒ Patella and medial and lateral patella facet ‒ Fluctuation test ‒ Medial and lateral patellofemoral ‒ Ballotment retinaculum ‒ Medial and lateral collateral ligaments ‒ Popliteus ‒ Assess for crepitus with knee extension

3 Strength Testing Range of Motion

• Strength Testing: • Have the patient move to a supine and • With the patient still sitting and knee joint relaxed position: flexed to 90°perform isometric strength ‒ Active Range of motion: -3 to 135-140° testing for leg extension and flexion. ‒ Passive Range of motion: -3 to 135-140° • Grade this on a 5/5 scale.

Special Tests Special Tests

• There are a multitude of special tests with • Divide knee special tests into three a variety of different names. subsections • Endeavor to understand the concept of the ‒ Patellofemoral articulation/extensor tests that you are performing and the mechanism specific structure that you are testing ‒ Mensical and chondral evaluation instead of memorizing the name of the ‒ Knee instability person that first described the test. • Medial and Lateral • Anterior and Posterior

4 Patellofemoral Articulation/ Patellofemoral Articulation/ Extensor Mechanism Extensor Mechanism

• Then have the patient move to • Measuring the Q angle full extension ‒ Measure q angle at ‒ Patella quadrant glide 30° of flexion to move ‒ Patella tilt the patella into the ‒ Patellar proximal portion of the subluxation/apprehension trochlea test • Males ≤ 10° ‒ Assess for pain with patella • Females ≤ 15° palpation, compression test and also with quad activation

Meniscal and Chondral Meniscal and Chondral Evaluation Evaluation • Pain at the joint line with palpation and with passive flexion • Apley Test: can be positive for a meniscal injury ‒ Patient is prone with the knee flexed to 90o. The knee • McMurray’s test is then pushed anteriorly and twisted. ‒ Attempt to grind the torn with compression ‒ Then the knee is pulled while twisting it. and rotation ‒ If pain is felt with the compression portion of this and ‒ Assess for pain at the joint line of the affected not with the distraction portion, it is considered meniscus and also a popping sensation positive. • Medial meniscus: ‒ The knee is flexed and a varus stress is applied while • If there is no difference with compression and the leg is externally rotated. During extension, the distraction, consider an articular chondral lesion over a patient will feel pain at the medial joint line and fibrocartilaginous menisical lesion snapping or popping will be appreciated at the medial • Thessaly’s Test: joint line. ‒ Have the patient stand on one leg. (you may need to • Lateral meniscus: assist with balance) ‒ The knee is flexed and a valgus stress is applied while ‒ Ask the patient to flex to 20o and then twist on the the leg is internally rotated. During extension, the knee. patient will feel pain at the lateral joint line and snapping or popping will be appreciated at the lateral ‒ Pain at the joint line or a catching/popping sensation is joint line. considered a positive test.

5 Medial and lateral Knee Knee Instability Instability • Stabilize the knee joint with the assistance of your and : • Anterior and posterior tibial/femoral ‒ Apply a varus stress the knee at 0o and 30o to assess for laxity of the Lateral Collateral • Medial and lateral tibial/femoral Ligament (LCL) ‒ Apply a valgus stress the knee at 0o and 30° to assess for laxity of the Medial Collateral Ligament (MCL) ‒ It is important to stress the knee in both full extension and also 30oof flexion. • At full extension, the cruciate ligaments, the posterior capsule and the condyles can restrict motion and can give a false negative

Medial and lateral Knee Anterior Instability Instability ‒ When performing the test, the examiner takes • : note of increased laxity when stressing the ‒ With the patient supine and the heel on the o ligament: examination table, flex the knee to 30 and slightly externally rotate the leg. • 0-5mm: grade 1 ‒ Ask the patient to relax. Stabilize the distal • 5-10mm with hard end point: grade 2 femur with one hand and grab the proximal tibia with the other. • >10 mm with soft endpoint: grade 3. ‒ Apply an anterior force to the tibia relative to • Pain does not make this test positive but the femur. rather laxity. • The heel should not rise up off of the table. ‒ The examiner will assess for a firm endpoint or • One may note pain at the contralateral joint a feeling of a rubber band snapping on itself. line from which you are stressing for meniscal injury or advanced .

6 Anterior Instability Anterior Instability

‒ Lachman can be graded as: • Anterior : • Negative: no increased translation ‒ Place the patient supine and flex the hip to 45o and the • Grade 1: 0-5mm increased translation, knee to 90o. • Grade 2: 5-10 mm increased translation ‒ Stabilize the tibia by gently sitting on the foot. ‒ The tibia should be in neutral rotation and the • Grade 3: greater than 10 mm increased hamstrings should be relaxed. translation or no endpoint noted. ‒ It is important to start with the knee in neutral position. ‒ This test can be modified if the patient has • A PCL tear may give a false positive anterior drawer large thighs or if the examiner has small hands test if the examiner does not start in neutral. by placing a knee under the distal hamstring to ‒ The tibia is then stressed to move anterior to the move the knee into 30o of flexion femur. Anterior drawer test is graded similar to the Lachman test: ‒ Sensitivity = 96% for diagnosing complete • Negative: no increased translation tears • Grade 1: 0-5mm increased translation • Grade 2: 5-10 mm increased translation • Grade 3: greater than 10 mm increased translation or no endpoint noted.

Anterior Instability Posterior Instability • Pivot shift test: • Posterior drawer test: ‒ Place the patient in the supine position and ask them to relax. ‒ Place the patient in the supine position ‒ The ankle is grasped with one hand and the with the hip flexed to 45o and the knee proximal tibia with the other while the knee is held in flexion. flexed to 90° ‒ Internally rotate the knee and apply a valgus stress as the knee is slowly extended. ‒ The tibia remains in neutral rotation. ‒ A positive test is posterior sliding (reduction) ‒ Stabilize the lower extremity by sitting of the lateral tibia plateau at about 30o of flexion. on the patient’s foot. • This is secondary to the iliotibial band ‒ Attempt to translate the tibia posteriorly which has a posterior force on the knee in flexion and an anterior force on the knee in relative to the femur. extension. • An ACL deficient knee is anterior laterally ‒ A positive test is increased posterior unstable. translation.

7 Posterior Instability Posterior Instability

• Sag sign: • Gravity sign: ‒ Patient is supine with both the and ‒ Patient is supine, the hips are flexed to knees flexed to 90o. 45o and the knees flexed to 90° ‒ Rest one hand under the knees and one hand gently supports the feet. ‒ Observe for posterior translation of the ‒ Observe for a posterior translation of the tibia tuberosity of the affected knee tibia relative the contralateral side. versus the contralateral knee. ‒ An important point to also consider when ‒ This test can be accentuated with quad evaluating a PCL injury is varus and valgus activation. stress testing of the knee: • Increased laxity at both 0 and 30o may indicated a collateral ligament injury with a concomitant PCL/ACL injury.

Common Knee Objectives Disorders • Discuss several most common knee disorders seen in primary care clinic. • Give common presenting symptoms Clinton Hartz, MD and exam findings Assistant Professor – Clinical Department of Family Medicine • Review some the recent literature on Division of Sports Medicine treatment guidelines for several knee The Ohio State University Wexner Medical Center disorders

8 Patellofemoral Syndrome/ Case #1 • 32 yo female who is a recreational runner • Pain Location presents with left knee • Non-specific or vague (medial, lateral or pain. Pain worse with infra patellar) getting up from sitting • Aggravated by loading patellofemoral joint position, going up and (PFJ) down steps. Denies any • Going up and down steps trauma or instability. • Rising from sitting position Has occasional “clicking” and trace swelling.

Patellofemoral Syndrome Patellofemoral Syndrome

• Physical Exam • Look beyond the knee for contributing • Positive patellar compression testing factors • Pes planus • May have trace effusion • Crepitus/clicking under patella with knee flexion • Weak hip muscles

• Treatment • Glut medius • Responds well to • Glut minimus • Home exercises • Valgus deviation

• Anti-inflammatory • Single leg squatting • Rarely need injections • Not balance

9 Patellofemoral Syndrome Patellar Tendinopathy

• Ferber et al. 2015 Strengthening of the Hip and • aka “Patellar Tendonitis” Core Versus Knee Muscles for the Treatment of Patellofemoral Pain: A Multicenter Randomized • Pain location Controlled Trial. • Inferior pole of patella most common • HIP and KNEE rehabilitation protocols • Worse with jumping activities (i.e. produced improvements (6 weeks). Basketball,volleyball, climbing stairs) • Although outcomes were similar, the HIP • “Jumper’s Knee” protocol resulted in earlier resolution of pain and greater overall gains in strength

Patellar Tendinopathy Patellar Tendinopathy

• Physical Exam • Treatment • May see quadriceps wasting • NSAID’s • Formal PT to work on core, hips and • Tender inferior pole patella or distal quadriceps tendon • Failed conservative treatment can • Unusual to see any swelling consider referral for prolotherapy, PRP (experimental) or ultrasound guided tenodesis.

10 Fat Pad Impingement Fat Pad Impingement

• Hyperextension injury common • Physical Exam • Tender in fat pad region (inferior pole • Pain Location patella, deep to tendon) • Pain inferior pole patella • “Puffy” appearance • Exacerbated by stairs, prolonged • Active extension may be painful standing, knee extension

Fat Pad Impingement Patellar Dislocation

• Treatment • Traumatic or Atraumatic • Formal PT to work on muscle training • Twisting or jumping with sensation of • Improve lower limb biomechanics “popping out,” pain and immediate swelling • Reduce spontaneously with knee extension and lateral pressure over patella

11 Patellar Dislocation Patellar Dislocation • Physical Exam • Treatment • Depend on presentation • • Atraumatic can be treated conservatively • Positive lateral –physical therapy, bracing as needed patellar apprehension • Acute Traumatic • Tenderness over • Conservative vs surgical medial border patella • Physical Therapy • X-ray’s should be –goal to reduce recurrence performed –Lengthy rehab ~12 weeks

Patellar Dislocation Case #2 • Bitar et al. 2012 Traumatic Patellar • A 21 yo male soccer player presents to Dislocation Nonoperative Treatment your office for evaluation of . He Compared With MPFL Reconstruction was trying to make a lateral cut to the ball Using Patellar Tendon when he felt a “pop” in his knee with • Treatment with MPFL reconstruction using significant pain. He developed swelling the patellar tendon produced better results, almost immediately, with some associated based on the analyses of posttreatment instability. On exam, he has notable knee recurrences and the better final results of effusion, a soft end point on Lachman the Kujala questionnaire after a minimum testing, and opens with valgus stress. follow-up period of 2 years. What is the diagnosis?

12 Anterior Cruciate Ligament Injury ACL Injury

• Complete vs Partial tear • Physical Exam • Pain Location • Restricted movement (esp loss • global extension) • most complete very painful initially • Lateral/medial joint line tenderness • unable to continue activity • Positive Lachman (Compare to other • immediate swelling () side) • Xray needed

ACL Injury ACL Injury • Treatment • Frobell et al. BMJ 2013 Treatment for acute anterior cruciate ligament tear: five year • Conservative vs Surgical outcome of randomised trial • Age of patient • A strategy of rehabilitation plus early ACL reconstruction did not provide better results • Degree of instability at five years than a strategy of initial rehabilitation with the option of having a later • associated injury (ie. MCL, meniscus) ACL reconstruction. • Type sports/activity level/occupation • Results did not differ between knees surgically reconstructed early or late and • Physical therapy those treated with rehabilitation alone.

13 Medial Collateral MCL Strain Ligament Strain • Physical Exam • Valgus stress pain and instability (joint • Can be associated with ACL injury or alone opening) • Caused by valgus stress • Pain Location • Valgus stress at 0o and 30° • Compare with contra-lateral side • mostly medial • Feel for end point • Soft tissue swelling • May get laxity at 0o with a torn PCL/ACL • May also try Anterior drawer test with • Pain with flexion knee external rotation to test the MCL

MCL Strain MCL Strain • Treatment • 3 Types (I, II, III) depending on severity of joint line opening • Type I- RICE, NSAIDs, home exercises and • Grade I: No increased instability, firm consider formal PT endpoint, pain with palpation at MCL, negative • Type II- relative rest (if pain with walking meniscus tests (<5mm instability) • Grade II: Increased instability, but end point is consider crutches), early ROM and HEP, still present, pain with provocative testing formal PT for ~8weeks, and hinged knee (6-10mm) brace as needed • Grade III: Gross laxity with mushy endpoint or no endpoint, (bony block) • Type III- same as type II but depending on • May not have pain as there are no fibers left to activity/occupation may need surgery. stress (>10mm) • Unusual to have isolated Type III without ACL or meniscal injury.

14 Case #3 Knee Osteoarthrosis

• A 54yo male presents to your office for • Pain location evaluation of right knee pain that has been getting progressively worse for the • joint line, most typically medial last 2-3 years. Denies any trauma, but • Night mostly has noticed some instability, and “popping” with going up and down steps. He also states his knee feels “swollen.” X-rays are pending. What’s your likely diagnosis?

Knee Osteoarthrosis Knee

• Insidious onset • Treatment • Unload joint • Gradual wearing • Weight loss!!! down of the articular • PT • Unloader brace

• spurs are a • Pain medications adaptation to abnormal • Analgesics forces in an effort to • NSAIDS spread out forces

15 Knee Osetoarthrosis Knee Osteoarthritis

• Injections • AAOS 2013 • Corticosteroids • Self-management programs, strengthening, low- • Viscosupplementation impact aerobic exercises, and neuromuscular • Pro-inflammatory education and engage in physical activity • PRP consistent with national guidelines

• Weight loss for patients with symptomatic OA of the knee and a body mass index ≥25 • Surgery • Total or hemiarthroplasty • Unable to recommend for or against the use of a • No meniscectomy for partial tearing valgus-directing force brace (medial compartment unloader) for patients with symptomatic OA of the or degenerative changes knee.

Knee Osteoarthritis Knee Osteoarthritis • We are unable to recommend for or against • We cannot recommend using glucosamine and the use of acetaminophen, opioids, or pain chondroitin for patients with symptomatic OA of patches for patients with symptomatic OA of the knee the knee

• We recommend non-steroidal anti-inflammatory • We are unable to recommend for or against drugs (oral or topical) or tramadol for patients with the use of intra-articular corticosteroids for symptomatic OA of the knee. patients with symptomatic OA of the knee.

• We cannot recommend using HA for patients with symptomatic OA of the knee

• We cannot recommend performing arthroscopy with lavage and/or débridement in patients with a primary diagnosis of symptomatic OA of the knee.

16 Knee Osteoarthritis Knee Osteoarthrosis • R. Bannuru et al. 2014 Relative efficacy of • We are unable to recommend for or against hyaluronic acid in comparison with NSAIDs for arthroscopic partial meniscectomy in patients with OA of the knee with a torn meniscus. knee osteoarthritis: A systematic review and meta- analysis meta-analysis • The practitioner might perform a valgus- • Suggests that IAHA is not significantly different producing proximal tibial osteotomy in from continuous oral NSAIDs at 4 and 12 weeks. patients with symptomatic medial • Only a short follow-up duration. compartment OA of the knee. • Given the favorable safety profile of IAHA over NSAIDs, this result suggests that IAHA might be a viable alternative to NSAIDs for knee OA, especially for older patients at greater risk for systemic adverse events

Meniscal Tears Meniscal Tears • Can be medial or lateral • Physical Exam

• Typically a twisting injury • Pain at joint line

• Swelling occurs but usually 4-8 hours later • Mechanical symptoms • secondary to synovial effusion • McMurray’s • Occasional instability • Pain with hyperextension

• True locking (Mechanical symptoms) • Pain with hyper flexion • Bucket handle flap tear • Rare • Effusion • Inability to fully extend

17 Mensical Tears Meniscal Tears • Physical Exam • Treatment • McMurray’s • Typically conservative • May feel a click • Sensitivity: 26-58% • Rehabilitation for a month • Specificity: 93-94% • Caution if mechanical symptoms • Apley’s Grind • Locking • Distraction: collateral ligament injury • True Buckling • Thessaly’s • Surgical intervention • More accurate than McMurray • Arthroscopy • Probability of injury if positive: 81% ) • Probability of injury if negative: 1% • Partial menisectomy • Meniscus Repair • Caution with concomitant osteoarthrosis

Meniscal Tears Meniscal Tears • Herlin et al: 2013: • R. Sihvonen et al 2013 Arthroscopic Partial • 96 patients: No difference in pain after arthoscopic menisectomy plus therapy Meniscectomy versus Sham Surgery for a versus therapy alone – 5 years Degenerative Meniscal Tear. • 129 patients without knee osteoarthritis but • Yin 2013: with symptoms of a degenerative medial • 102 patients: No significant differences between arthroscopic meniscectomy and nonoperative mgt with strengthening • The outcomes after arthroscopic partial exercises in terms of relief in knee pain, improved knee function, or increased meniscectomy were no better than those satisfaction in patients at 2 years after a sham surgical procedure.

18 /bursitis

• Pain Location • Bursa located under sartorius, gracilis, • Pain Location semitendinosus tendons • Lateral knee pain, • Anteromedial knee pain, over bursa, common in long- possible swelling distance runners, • Treatment cyclists • Activity modification, anti-inflammatories • Precipitated by PT downhill running • Consider corticosteroid injection

Iliotibial band Conclusion syndrome/bursitis • Knee pain is common patient complaint

• Pain Proximal to lateral joint line • History and physical and mechanism of injury very important in developing diagnosis • Ober’s test positive • Treatment • Mechanical symptoms (locking, catching) or • Activity modification, anti- instability on exam requires further work up inflammatories, PT. Consider foot (MRI and/or referral) orthotics. Possible injection • Many knee disorders can be treated conservatively with good physical therapy, short term NSAIDs and possible injection.

19