A Standardized Approach Basic Approach to the Knee Examination • Inspection • Palpation • Strength Testing Bryant Walrod, MD • Range of Motion Assistant Professor – Clinical Department of Family Medicine • 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 knees bent. miss anything. ‒ Observe for an obvious dislocation of the patella or • One also needs to ensure adequate knee joint. exposure • Evaluate for an effusion ‒ Have the patient get into shorts to fully versus a bursitis. 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 • Genu recurvatum • 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 fibula 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 meniscus 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 hip and arm: • 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 • Lachman Test: 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 arthritis. 6 Anterior Instability Anterior Instability ‒ Lachman can be graded as: • Anterior drawer test: • 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 hips 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 Chondromalacia Patellae • 32 yo female who is a recreational runner • Pain Location presents with left knee • Non-specific or vague (medial, lateral or pain.