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The History Exam William Hey 1795 Steve E. Jordan M.D. Internal Derangement

Andrews Institute of the Knee Gulf Breeze, FL

Orthopaedics Turn of the Century 1889 Polio “Now, however, a Scoliosis change has come over the scene; life is lived at Tuberculosis higher pressure, and Hip Disease competition is greater than it used to be; Foot Problems anything that clogs the Crippled Children wheels of life entails on the sufferer loss of health, of time, and of money, incapacitates Casting him from some occupations, and debars Bracing him from some Incision pleasures and Amputation invigorating sports.”

Augustus Thorndike, M.D.

Harvard Team Physician

“ Such then is a routine examination that will enable one to arrive at a diagnosis at all of the important knee injuries”

1938

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Don O’Donoghue, M.D.

“The examination of the patient may, of course, often solve Treatment of Injuries the difficulty.” to Athletes 1962 “ Careful, tender but meticulous complete examination of every sprain of the knee”

The Book that Launched Sports Medicine as a “The decision to operate or not depends on the results of a Specialty careful examination ”

Don O’Donoghue, M.D.

The Knee Exam Organizing the Exam

History Character Location Duration Aggravation Relief Activity Unique • Inspection Inspection • • Anterior Knee Palpation • Meniscal Exam • Ligamentous Exam Tests

Inspection Palpation

Not Just Effusion

Tenderness Hips Peri-Patella Plica Line Medial Lateral Musculature MCL LCL origin/insertion

Lower Leg Rotation Patellar Tendon Tibial Tuberosity

Foot and Ankle Alignment ASK Where?

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Dr. Hughston Patello- Femoral Joint Goldthwait 1904 Boston Med J Subluxation of the Patella • Q angle JBJS 1968 • Patella Alta • Trochlear dysplasia • Medial Laxity “Grating”

Fairbank 1936 Proc Royal Soc Lateral Posture Apprehension Sign VMO Dystrophy Passive Subluxation Hughston 1968 JBJS Medial Tenderness • Subluxation of the Patella

Insall 1976 JBJS • Chondromalacia Patellae

Patello --- Femoral Joint Observation Patellar Tracking

• Position - Baja Alta • Quadriceps “Q” Angle

• Tracking in Flexion and Extension “J tracking”

Apprehension Test Patello - Femoral Tests (Fairbank’s Test)

• Tilt Test Knee Flexed 30◦ Lateral Stress • Glide Test Pos. Test • Grind Test (Clarke’s Sign) Apprehension

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P-F Instability OOPs! Dorsal - Fin Patella “Moving Patellar Apprehension Test”

2 Parts Flexion with Lateral Stress Flexion with Medial Stress

Pos. Test = Apprehension Lateral Only

SN 100% NPV 100% Accuracy 94% Ahmad 2009 AJSM

Meniscal Exam Meniscal Tests Tenderness or Clicks Pain with Rotation Joint Line Palpation Apley’s Grind Test Bragard Test Bohler Test Steinmann 2 nd Test Helfet Test McMurray’s Test Payr’s Test Steinmann 1 st Test Merke’s Test Blocked Extension Ege’s Test Bounce Test Thessaly Test Knee Jerk Test (Oni) Anderson’s Grind Test McGinty Test

Allingham 1889 McMurray’s Test

Palpation T.P. McMurray Joint Line Tenderness The Semilunar “Essential Part of Exam” Br Journal of Surgery 1942

“This method of evaluation is of little value if the lesion SN: 30-90% is anterior to midline” SP: 30-95%

Accuracy 81% 90% Positive Test: LR+ better for Lateral Painful Click or Snap

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Medial – Lateral or Anderson’s Grind Test Bounce Test “Bounce Home Test”

Anderson & Lipscomb Allingham AJSM 1986 Internal Derangements of the Knee Joint Apply Varus and Valgus London 1889 Flexion and Extension

SN: 35-50% Pos = “grinding sensation” SP: 65-85%

SN SP : 70% LR+ 1.5-2.5 False positives Infrequent

ApleysApleys’’ Test Thessaly Test aka “Disco Test”

Apley A.G. JBJS 1947 The Diagnosis of Injuries- New Methods A New Clinical Test for Early Clinical Detection of Meniscal Teas Prone Karachalios , et al JBJS 2005

Compression + Rotation Performed @ 20° Flexion Pain = Accuracy 94% 96% Distraction + Rotation Pain = Ligament Sprain

Evidence Meniscal Tests Evidence Summary Meniscal Tests • Solomon - JAMA 2001 - Meniscus LR+ <3 Combination is recommended • Exam plus History improves Accuracy • Rob - J Fam Prac 2001 – Meta Analysis • Experience with the tests improved accuracy McMurray’s highest PPV • Malanga - Arch Phys Med Rehab 2003 • All tests trended less accurate with concomitant McMurray’s high SP JLT high SN ligamentous injuries • Lowery - 2006 - • Tests were more accurate in young pts and acute Composite Score 5 tests- (includes history) PPV 92% injuries, less so with degenerative knees • Bartz CORR 2007 – Review “no constant and pathognomonic sign exists” • Combinations including JLT were best • Konan - Knee Surg Sport Arth 2009 - JLT best plus Thessaly / McMurray’s Better - 95%

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History Ligamentous Exam MCL Medial Collateral Ligament

George Noulis 1875 Paris Pt. Supine “Sprains of the Knee” Abdxn Rocking

Hey Groves 1917 London Apply Valgus Stress “On passive manipulation.. the diagnosis is a matter of considerable certainty” 30 degrees Sir Robt Jones 1923 London 0 degrees “The diagnosis therefore of a ruptured crucial ligament should not be very difficult” Grades I-III A. Thorndike 1938 Harvard “marked increase in the ant-post mobility suggests injury to the crucial ligaments”

LCL Lateral Rotatory Instabilities Collateral Ligament ALRI PLRI Ant Drawer Dial Test Pt. Supine Pivot Shift MacIntosh PL Ext Rot Test Apply Varus Stress Jerk Test Hughston Ext Rot Recurvatum Losee Test Postero Lateral Drawer 30 degrees Side Lying Test Slocum Reverse Pivot Shift Test 0 degrees Flexion Rot Drawer Noyes

Grades I-III AMRI PMRI Slocum Test Larson

Anterior Lachman’s TestTestTest

Knee Flexed 90 ° in Neutral “Clinical Diagnosis of ACL Instability in Endpoint Firm – Soft - Absent the Athlete” Torg, et al, AJSM 1976 Accuracy in Acute Injuries Poor Accuracy 95%

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Lachman’s TestTestTest Pivot Shift Test

Patient Supine Relaxed Galway , MacIntosh 1980 Clin Ortho Flexion - 30 Degrees Sign and Symptom Tibia Neutral R/O Posterior Subluxation Is Anterior Laxity Clinically Significant? Grading: I - II – III Firm – Soft - Absent Extension Int Rot. Valgus Slow Flexion

PCLPCLPCL Posterior Instability ACL Lelli Test

PCL Primary Posterior Restraint Twice as strong as ACL Bigger Patients AL Bundle 80%

Smaller Examiner PLC injuries seen in 60% of PCL injuries

Posterior Drawer Posterior Sag Test Quadriceps Active Test

History PCLPCLPCL Post SAG Test

First written PE “sign” Static Test Thorndike Posterior Sag Sign 80% Sensitive 100% Specific Thorndike 1938

Supine Knees at 90° Feet flat on Table Relax Quadriceps

Observe from Side

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PCLPCLPCL Posterior Drawer PCLPCLPCL Quadriceps Active

Most Sensitive Test for Daniel JBJS 1988 Isolated PCL Accuracy is 60% +

90% Sensitive 99% Specific Supine - Knee at 90° Feet flat on table Tibial plateau 1 cm Anterior to MFC Ask to slide foot forward

Endpoint Not as reliable as > 2mm anterior motion Translation = Pos Test

Posterolateral Corner Complete Exam Dial Test Pt Supine History - Inspection - Palpation - ROM Knees Flexed 30◦ 90◦ P F J - Position- Tracking- Palpation Tilt - Glide - Apprehension

“Dial” feet externally Meniscal - JLT - McMurray - Grind - Bounce

> 15◦ difference MCL /LCL - Stress tests @ 30 deg and 0

= positive test ACL /PCL - Drawer - SAG - Lachman – Pivot Shift – Dial Quadriceps Active Test (PCL)

Thank You !

Leandra Price ATC Jimmy Sims Video

Ashley Ramsey ATC

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