Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions

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Review Article Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions

Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Its Joseph C. Schaffer, MD superficial anatomy enables diagnosis of the injury through a thorough history and physical examination. Examination techniques for the knee described decades ago are still useful, as are more recently developed tests. Proper use of these techniques requires understanding of the anatomy and biomechanical principles of the knee as well as the pathophysiology of the injuries, including tears to the menisci and extensor mechanism, patellofemoral conditions, and osteochondritis dissecans. Nevertheless, the clinical validity and accuracy of the diagnostic tests vary. Advanced imaging studies may be useful adjuncts.

ecause of its location and func- We have previously described the Btion, the knee is one of the most ligamentous examination.1 frequently injured joints in the body. Diagnosis of an injury General Examination requires a thorough knowledge of the anatomy and biomechanics of When a patient reports a knee injury, the joint. Many of the tests cur- the clinician should first obtain a rently used to help diagnose the good history. The location of the pain injured structures of the knee and any mechanical symptoms were developed before the avail- should be elicited, along with the ability of advanced imaging. How- mechanism of injury. From these From the Division of Sports Medicine, ever, several of these examinations descriptions, the structures that may Department of Orthopaedics, are as accurate or, in some cases, University of Rochester School of have been stressed or compressed can Medicine and Dentistry, Rochester, more accurate than state-of-the-art be determined and a differential NY. imaging studies. diagnosis can be formulated. Pre- To evaluate knee pathology, Neither of the following authors nor vious injuries should also be sought any immediate family member has familiarity with examination tech- because the current injury may be the received anything of value from or has niques for the menisci, extensor sequela of a prior insult. stock or stock options held in a mechanism, patellofemoral condi- commercial company or institution As with any physical examination, related directly or indirectly to the tions, and osteochondritis dissecans an orderly routine is of great impor- subject of this article: Dr. Bronstein (OCD) and with the associated tance. When the knee is evaluated, the and Dr. Schaffer. anatomy and biomechanics is essen- sequence should involve inspection, J Am Acad Orthop Surg 2017;25: tial. Methods that increase diagnostic assessment of active and passive 365-374 sensitivity and accuracy should be range of motion (ROM), palpation, DOI: 10.5435/JAAOS-D-15-00464 incorporated. Advanced imaging, and special tests, with any potentially such as MRI, can then be used as uncomfortable tests performed last. Copyright 2017 by the American Academy of Orthopaedic Surgeons. necessary but should not replace the To ensure a thorough examination, history and physical examination. both of the patient’s lower extremities

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Figure 1 musculature, particularly the quad- the area of discomfort and examining riceps, should be inspected for atro- the area of reported pain last. A sug- phy. In addition, the patella should be gested approach is to begin anteriorly assessed for malalignment, which and work posteriorly, starting with may predispose the patient to mal- the quadriceps tendon and then pal- tracking or patellar dislocation. pating the patella, patellar tendon, Patella alta or baja is generally as- and tibial tuberosity. Next, the medial sessed with the patient in the seated and lateral patellar facets can be pal- position and can be confirmed pated while assessing for the appre- radiographically. hension sign. Then the medial and Any localized swelling and masses, lateral joint lines should be palpated Clinical photograph demonstrating including swelling of the prepatellar and the remainder of the examination knee effusion by “milking” the fluid bursa, a meniscal cyst, and Osgood- performed, including specific tests for from the suprapatellar pouch with one hand. The other hand palpates Schlatter disease of the tibial tubercle, ligaments and menisci. As noted pre- the so-called balloon of fluid. should be noted. A popliteal (ie, viously, any test that is expected to Baker) cyst can be palpated posteri- cause pain should be done last. orly with the knee extended. Swelling Finally, it is important to remember should be fully exposed. An of the distal femur or proximal tibia that pain felt in the knee may be assessmentofgaitshouldbeper- may indicate a neoplasm or infection. referred from other locations, including formed first, looking for varus or The knee should be inspected for a the spine and the hip. A careful history valgus, quadriceps avoidance, and prepatellar or intra-articular effu- can help differentiate referred spinal antalgic gaits. Substantial primary sion. An effusion of the prepatellar pain. Routine examination of the hip varus or valgus deformity may be bursa is anterior to the patella; with and spine is recommended when eval- the result of single-compartment an intra-articular effusion, the patella uating knee pain, with particular osteoarthritis. With quadriceps remains palpable subcutaneously. attention paid to loss of hip rotation. avoidance, the patient bears weight On inspection, a true knee joint with a knee locked in extension effusion is often best appreciated in because of either a weakened the suprapatellar pouch. The effusion The Menisci extensor mechanism or pain. An can be “milked” from the supra- antalgic gait can result from any patellar pouch with one hand, while The medial and lateral menisci are condition causing knee pain. the other hand palpates the effusion crescent-shaped cartilaginous struc- Next, an assessment of standing (Figure 1). tures, triangular in cross-section, that limb alignment should be performed, Next, ROM should be assessed, serve important biomechanical func- taking note of specifics, such as pes first with active motion and then with tions in the knee. These include load planus and excessive femoral ante- gentle passive motion if necessary. bearing, shock absorption, joint sta- version, both of which can contribute Compared with the contralateral bility and congruity, joint lubrication, to patellofemoral tracking problems. knee, the injured knee may fail to and proprioception. As early as 1803, Excessive femoral anteversion may reach full passive extension, which Hey2 recognized injury to the menis- be identified by an inward-pointing may indicate a mechanical block or cus as a cause for locking of the knee. or so-called squinting patella. hamstring spasm. Limited ROM is The biology, anatomy, development, The patient should then be posi- expected with large knee effusions or and degeneration of the meniscus tioned supine on an examination pain. Although full ROM is required were described by McMurray.3 The table. The uninjured knee should be for a complete knee examination, it is injury mechanism is typically a twist- examined first. This relaxes the not always possible at the first visit ing moment through the knee in the patient and helps to reassure him or and should not be forced. A short flexed, weight-bearing position.4 Pain her that the examination will not course of physical therapy with re- experienced at the time of injury is cause pain, while also accounting for examination in several days to 1 week variable, followed by the insidious individual variations between the can be helpful. onset of an effusion over the next day. uninjured knee and the contralateral Tenderness on palpation combined Patients may experience mechanical knee. We have found that telling the with knowledge of knee anatomy is symptoms, such as catching, locking, patient to relax his or her hip as well especially useful for diagnosis. Pal- clicking, or instability, and usually as the knee facilitates passive motion pation should be done systematically, report either medial or lateral knee and instability examinations. The altering the approach depending on pain.

366 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

Figure 2

A, Clinical photograph showing the lateral McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is internally rotated (white arrow), engaging the posterior horn of the lateral meniscus under the lateral femoral condyle. The knee is then extended (black arrow), entrapping the meniscus. B, Clinical photograph showing the medial McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is externally rotated (white arrow), engaging the posterior horn of the medial meniscus under the medial femoral condyle. The knee is then extended (black arrow), entrapping the meniscus.

The lateral and medial menisci dif- With the patient supine, the knee is Of note, McMurray3 did not men- fer somewhat in anatomy. The lateral fully flexed, and the examiner tion varus or valgus stress. Some meniscus is more circular and mobile, grasps the foot with one hand and authors have added varus and valgus whereas the medial meniscus is more steadies the knee with the other. stress to medial and lateral McMurray firmly attached to the capsule and The tibia is rotated internally and circumduction tests, respectively,5-7 medial collateral ligament and is the knee is extended to test for a although we have not found this subject to greater forces. This pre- lateral meniscal tear and then helpful. disposes the medial meniscus to more externally rotated and extended to frequent injury. test for a medial meniscal tear An effusion combined with joint (Figure 2). Anatomically, the pos- Apley Grind Test line tenderness (JLT) is one of the terior horn of the lateral meniscus In 1947, Apley4 presented his own most sensitive and reliable signs of a is brought under the lateral femo- test, arguing that McMurray’s meniscal tear.5 The joint line should ral condyle with flexion and approach was flawed. He specifically be palpated through the full ROM to internal rotation and is stressed as aimed to differentiate “rotational identify any subluxation or snapping the knee is extended. The medial sprain” from a meniscal tear, which of the hamstring over the medial meniscus is similarly entrapped he described as a capsular or collateral condyle or the biceps tendons over with external rotation (Figure 3). ligament sprain. As described by Ap- the fibular head, which can con- Although McMurray3 described a ley,4 his test requires that the patient found findings.3 Tenderness over the palpable click or clunk, the lie prone on an examination table no more distal pes bursa should be dif- maneuver has been modified so morethan2fthighsothatthe ferentiated from JLT. that pain along the tested joint line examiner can place his or her knee is considered notable. The test can over the patient’s posterior thigh, be performed only when the stabilizing the femur. With the knee McMurray Circumduction patient has full knee flexion. flexed 90°, the examiner powerfully Test Because the test is designed to rotates the tibia externally, first McMurray3 described a circum- displace an occult posterior horn neutrally loaded, next in distraction, duction test to detect occult tears of tear, it may not be as useful for an and then in compression. Sub- the posterior horns of the menisci. already displaced meniscal tear. stantially increased pain in distraction

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Figure 3 and 60.7% and 70.2% for the Apley grind test. Another meta-analysis published soon after but including only 11 English-language articles indicated that the mean sensitivity and specificity were 55% and 77%, respectively, for the McMurray circumduction test; 76% and 77%, respectively, for the JLT test; and 22% and 88%, respectively, for the Apley grind test.10 This review,10 as well as another by Hing et al,11 confirmed the widely ranging values. Generally speaking, the McMurray circumduction test has relatively high specificity but low sensitivity, whereas the JLT test is thought to have higher sensitivity but lower specificity.11-13 Furthermore, in studies that reported Photographs of a knee model demonstrating the anatomic principles of the medial and lateral meniscus testing McMurray circumduction examination, with internal rotation of the tibia and entrapment of the lateral meniscus (A) and external tibial rotation and separately, the McMurray circum- entrapment of the medial meniscus (B). duction test had higher sensitivity medially but higher specificity laterally.11 Mariani et al14 suggested that compared with the neutral position circumduction, and Apley grind tests, differences in the anatomic attach- indicates a rotational sprain, whereas and several groups have systemati- ments of the two menisci, with the increased pain in compression indi- cally reviewed this pool of data. The medial being more fixed and the lat- cates a meniscal tear. Similar to reported sensitivity and specificity of eral being more mobile, contributed McMurray,3 Apley4 noted that the tests have varied widely, and the to this variation. More studies on the internal rotation can be applied to test published reviews have been limited diagnostic accuracy of these tests have the lateral meniscus and that a more by notable heterogeneity between been published recently and generally acute knee flexion angle can be studies; the variation has been agree with the trends reported in the applied to test the posterior horn. attributed to methodological flaws in systematic reviews.13,15-17 Because most clinical offices do not the study designs.8-11 have a 2-ft–high table for conducting The most comprehensive of these a test with substantial distraction, the systematic reviews was conducted Thessaly Test Apley grind test is now more com- by Hegedus et al9 in 2007 and monly performed with prone com- included 18 studies from English- and The Thessaly test, named for its pression and rotation. We have found German-language publications. The region of origin in Greece, was that patients with patellofemoral pain reported sensitivity and specificity described by Karachalios et al18 in oftenhavepainwithpronecompres- varied widely (from 15% to 74% and 2005. The test is intended to be both sion and rotation, so we have mostly from 11% to 97%, respectively, for easy to perform in the outpatient abandoned this test in our practice. the McMurray circumduction test; setting and more accurate in detect- from 27% to 95% and from 5% to ing meniscal tears than the existing 98%, respectively, for the JLT test; provocative tests are. The Thessaly Diagnostic Accuracy of and from 13% to 70% and from test is performed with the patient Meniscus Tests 33% to 100%, respectively, for the standing on one foot, which is fixed Apley grind test). The pooled sensi- flat on the ground (ie, first the normal Numerous primary studies have re- tivity and specificity, respectively, side for training, then the injured ported on the accuracy of various were 70.5% and 71.1% for the side), and with the knee at a fixed tests for diagnosing a meniscus McMurray circumduction test, angle of flexion (ie, first at 5°, then at injury, especially the JLT, McMurray 63.3% and 77.4% for the JLT test, 20°). The examiner supports the

368 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 patient by the hands, and the patient ally is somewhat incomplete and tend to be higher energy and occur internally and externally rotates his that diagnostic accuracy is in patients aged ,40 years. The or her body three times. This repro- increased when the tests are con- mechanism is usually an eccentric duces dynamic load transmission and sidered together.12 Indeed, despite load, such as stepping in a hole, stresses the meniscus. Medial or lat- the limitations of the individual missing a stair step, or jumping. eral joint line discomfort or popping tests for meniscal tears, combined Patients typically report a painful, constitutes a positive test result. testing has improved accuracy.8,15 swollen knee, a sensation of giving In the original article by Karachalios Several studies have compared the way, and inability to walk unas- et al,18 the 20° Thessaly test had a diagnostic accuracy of a composite/ sisted. In addition, they hold their medial sensitivity and specificity of combined clinical examination knee extended as much as possible. 89% and 97%, respectively, and a with that of MRI.21-25 Galli et al13 Examination of the extensor lateral sensitivity and specificity of compared clinical examination mechanism, like that of other ana- 92% and 96%, respectively; these with arthroscopic findings and tomic features of the knee, is guided results were superior to those of the concluded that a clinical evaluation by the patient history. A quadriceps 5° test as well as those of the by an experienced examiner is at or patellar tendon tear is diagnosed McMurray circumduction, Apley least as accurate as MRI in detect- by the inability to extend the knee grind, and JLT tests. A notable limi- ing meniscal lesions and recom- against gravity and a palpable defect tation was the exclusion of acutely mended proceeding directly to directly proximal or distal to the injured knees (ie, ,4weeks). arthroscopy without further imag- patella, combined with a history of an A follow-up study of meniscal tears ing after a positive McMurray cir- acute injury. In larger patients, it may reported 90.3% sensitivity and cumduction test result. Rayan be difficult to palpate the defect, 97.7% specificity for the 20° Thessaly et al21 compared the composite particularly a quadriceps tendon test, confirming the original find- physical examination (ie, including rupture. When a quadriceps or ings.19 In contrast, a second follow- McMurray circumduction and JLT patellar tendon rupture is suspected up study could not repeat the tests) with MRI, using arthroscopy and the defect cannot be palpated, diagnostic accuracy reported in the as the benchmark; physical exami- advanced imaging can be helpful. original paper, instead finding that nation had 86% sensitivity and Radiographs may also reveal patella the Thessaly test had accuracy similar 73% specificity for medial meniscal alta or baja (ie, an Insall-Salvati ratio to that of the McMurray circum- tears, which was somewhat better .1.2 or ,0.8, respectively).28 duction test.15 Another recent study than that of MRI, and 56% sensi- involving 593 patients with a sus- tivity and 95% specificity for lat- pected meniscal tear also reported eral meniscal tears, which was Patellofemoral Conditions lower accuracy with the Thessaly comparable to findings with MRI. The patella is a sesamoid bone with test (ie, 64% sensitivity and 53% We are confident in proceeding to medial and lateral facets separated by specificity), although the results arthroscopy with positive meniscal a ridge or crest. The medial and lat- were not significantly different from test results in conjunction with a knee eral facets vary in relative size. The rates observed with the McMurray effusion and normal radiographs. femoral trochlea provides bony sta- circumduction test.20 One study bility but also varies in configuration showed that the Thessaly test was and depth. The patellofemoral joint is less accurate in the presence of The Extensor Mechanism stabilized passively by patellofemoral anterior cruciate ligament tears, ligaments and retinacular constraints demonstrating that normal bio- The extensor mechanism is com- and is stabilized actively by the mechanics are important with use of posed of the quadriceps muscles, the quadriceps stabilizers. Patellofemo- provocative maneuvers for meniscal quadriceps tendon, the patella, and ral symptoms are generally classified tears.17 the patellar tendon and its insertion as either pain or instability.29 at the tibial tubercle. When ruptures of the extensor mechanism are iden- Composite Clinical tified early, outcomes (ie, repairs) are Patellofemoral Pain Examination Versus Magnetic improved; however, the initial mis- Resonance Imaging diagnosis rate is $39%.26,27 Patients commonly report anterior Quadriceps tendon tears usually knee pain. Although a detailed Some authors have noted that con- occurinpatientsaged.40 years,27 explanation of the various etiologies sidering diagnostic tests individu- whereas patellar tendon ruptures of anterior knee pain is beyond the

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Figure 4 manually displace the patella medially greater than one quadrant of the patellar width with the knee flexed at 20° to 30° and relaxed32 (Figure 4). Tenderness over the quadriceps tendon or patellar tendon may indicate tendinitis or tendinopathy.

Diagnostic Accuracy A prospective validation study of 106 patients scheduled for arthroscopic knee surgery found the Clarke sign had a sensitivity of only 39.1% and a specificity of 67.5% in assessing chondromalacia patella,31 providing A, Illustration showing a normal passive patellar tilt test. With the knee extended little to no diagnostic value. This and the quadriceps relaxed, an inability to lift the lateral patella off the horizontal finding was corroborated by other indicates tight retinacular structures causing patellar tilt. B, Illustration showing studies.12,33 the patellar glide test—30° of flexion. An inability to manually displace the patella medially at least one quadrant indicates a tight retinaculum. (Panel A reproduced The patellar tilt examination for from Dragoo JL, Tuman JL: Knee injuries and related conditions, in Limpisvasti O, patellofemoral pain had a sensitivity Krabak BJ, Albohm MJ, et al: The Sports Medicine Field Manual. Rosemont, IL, of 43% and a specificity of 92% in American Academy of Orthopaedic Surgeons, 2015, pp 337-361.) diagnosing PRPS.34 This test also had poor intraobserver and interobserver reliability in assessing scope of this article, patellofemoral femoral trochlea; pain constitutes a patellar instability (k = 0.05 and k = pain syndrome (PFPS) refers broadly positive test result. A more con- 0.08, respectively).35 to pain associated with patellofem- temporary and common version of Further reviews have confirmed oral articulation. The symptoms of the patellar grind test is known as that although many tests have PFPS are often exacerbated by pro- the Clarke sign or test, although to been described, to our knowledge longed sitting (ie, the so-called movie our knowledge, there is no record there are no truly valuable physical sign), climbing or descending stairs, of its origin in the literature.31 It tests for either chondromalacia or other activity. When patellofem- incorporates active contraction of patella or PFPS.31,33,36 Current oral pain is discussed, the term the quadriceps while the examiner test validation studies have been chondromalacia should be reserved braces the patella in the web space limited by the lack of a consistent for cases of physical damage to of the thumb, exerting compressive reference standard. According to the articular cartilage, diagnosed and inferior pressure. These two Cook et al,36 patellofemoral pain radiographically or by arthroscopic patella compression tests are remains a “multifactorial and neb- visualization. sometimes differentiated as passive ulous pathology,” which may be a versus active, but neither accurately diagnosis of exclusion. reproduces normal patellofemoral Tests for Patellofemoral Pain mechanics.12 Syndrome We prefer to palpate for patellar Patellar Instability Physical examination findings for facet tenderness by moving the patellofemoral pain include tender- patella medially and laterally while Patellar instability is common, affect- ness about the joint. In 1936, Owre30 palpating the medial and lateral fac- ing young, active persons and females described a patellofemoral grinding ets, respectively, although this more than males, and can be debili- test as follows: While the patient lies approach is still not specific. Tight- tating.37 Patients with true patellar supine with the knee extended and ness of the lateral retinacular struc- instability report either patella dislo- relaxed, the examiner places his or tures, which causes patellar tilt, may cation requiring reduction or lateral her fingers over the patella and be seen with PFPS. On examination, subluxation with spontaneous reduc- exerts pressure through the patella this is manifested as the inability to tion.29 The cause is multifactorial; medially and laterally, moving it lift the lateral patella off the hori- contributing factors include the bony superiorly and inferiorly against the zontal with the knee extended or to structure of the patella and femoral

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD

Figure 5

Clinical photographs demonstrating the Wilson sign. A, The knee is first flexed to 90°, and the tibia is internally rotated (arrow). B, The knee is then slowly extended with the tibia kept internally rotated (arrow); the patient reports pain as the tibial spine abuts the osteochondritis dissecans lesion on the medial femoral condyle at about 30° short of full extension. C, The pain is relieved by externally rotating the tibia (arrow), bringing the tibial spine away from the lesion. trochlea, integrity and/or laxity of the theoretically important because it teversion and by pes planus through surrounding tissues including the relates to the lateral displacement tibial external rotation. medial patellofemoral ligament, force on the patella. The Q angle is muscle tone and balance, and overall defined as the acute angle formed by limb alignment.35,37,38 lines drawn from the anterior supe- J Sign rior iliac spine to the center of the The J sign is an indication of patho- reduced patella and from the center of logic patellar tracking and refers to Q Angle the patella to the tibial tuberosity.39 the inverted “J” course of the patella The quadriceps angle, or Q angle, is a An angle $20° is often cited as as it subluxates laterally in full measure of the direction of pull of the abnormal, as recommended by Insall extension and then reduces into the quadriceps relative to the line of et al.39 The effective Q angle can be femoral trochlea in early flexion, action of the patella; this angle is increased by excessive femoral an- observable with both active and

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions passive motion.40,41 It is considered possibly related to repetitive sign may not be sensitive, conversion a sign of severe instability that is trauma and results in lamination from a positive to negative result is a difficult to treat38,41 and has been and sequestration with or without good indicator of clinical healing. associated with vastus medialis damage to the overlying articular No study has evaluated the diag- obliquus insufficiency;41 however, cartilage. Lesions occur primarily nostic performance of the Wilson sign recent evidence shows it more likely in the knee; most are located on the specifically. However, Kocher et al49 indicates a ligamentous problem or femur, with 70% on the lateral reported on the diagnostic accuracy trochlear dysplasia.42 Its clinical aspect of the medial femoral of a composite clinical evaluation, validity is questioned, however, condyle.46 including history, physical examina- because one study found the sub- Patients typically report poorly tion, and radiography, in pediatric jective J sign did not correlate with localized knee pain that worsens patients with knee disorders. The lateral patellar subluxation.42 Fur- with activity, particularly deep authors found that for OCD, the thermore, although it had moderate flexion activity, such as stair composite clinical evaluation’s sen- interobserver reliability (ie, k = climbing. Mechanical symptoms sitivity was 77.3% and its specificity 0.53), the J sign had poor intra- may be reported and indicate an was 97.9%. This study has notable observer reliability (ie, k = 0.28).34 unstable lesion or loose body. On weaknesses, but it does illustrate that examination, there may be a mild most OCD lesions are diagnosed Fairbank Apprehension Test effusion and point tenderness over primarily with radiography. There- the involved site. fore, the physical examination—and In 1937, Fairbank43 described a test the Wilson sign specifically—are for use in patients with suspected probably of little clinical value by recurrent patellar dislocation. He Wilson Sign themselves; however, by indicating a noted that patients had marked In 1967, Wilson47 observed that need for imaging, they may lead to a apprehension when the patella was patients with OCD of the medial correct diagnosis. pushed outward. The result is femoral condyle often had a specific considered positive only when the antalgic gait with external rotation of patient expresses apprehension or a the foot, which he proposed relieves Summary feeling of instability, rather than the pressure of the tibial spine on the pain. A positive sign is strongly medial femoral condyle. He then Knee pathology can be accurately suggestive of symptomatic patellar described a diagnostic test that diagnosedwithathoroughpatient instability,41,43 and the specificity incorporates this anatomic relation- history and physical examination. of the test has been moderately ship. First, the patient is positioned The described tests, along with an good (ie, 70% to 92%).36 The supine with the knee flexed to 90° understanding of knee anatomy and sensitivity of the test, however, has and the tibia rotated internally. Next, biomechanics,canbeusedtoreli- been low (ie, #37%),12,36 with lit- the knee is slowly extended. A posi- ably diagnose most meniscal and tle to no interobserver reliability.35 tive test result is recorded when the ligamentous injuries. Radiography A patellar glide of more than two patient reports pain as the tibial spine should be performed for all patients quadrants can indicate a lack of abuts the OCD lesion on the medial with knee injury, and weight- medial patellar restraints. femoral condyle at approximately bearing views should be obtained 30° short of full extension. The pain when arthritis is suspected. MRI, is relieved as the tibia is externally which can be helpful in some cases, Osteochondritis Dissecans rotated, which brings the tibial spine is not always necessary and should away from the lesion (Figure 5). never be performed in lieu of a his- OCD is a disease of uncertain eti- tory and physical examination. ology primarily in children and young adults that can lead to irre- Diagnostic Accuracy versible damage of articular carti- In a study of 32 patients, Conrad and References lage and subchondral bone. It Stanitski48 found that only 25% of was first described by Paget44 in patients with radiographic evidence of Evidence-based Medicine: Levels of 1870 as “quiet necrosis” and was medial femoral condyle OCD had a evidence are described in the table of then termed “osteochondritis dis- positive Wilson sign at the initial visit; contents. In this article, references secans” by König45 in 1887. The however, these patients converted to a 14, 17, 18, 33, 34, and 42 are level I suspected cause is a vascular insult negative Wilson sign with lesion res- studies. References 7, 15, 16, 20, 22, to the subchondral bone that is olution. This means that although the 23, and 28 are level II studies.

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD

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