Physical Exam of the Knee Andrews Institute Rehabilitation Symposium March 1, 2019 Steve E. Jordan, M.D. The Andrews Institute History William Hey of Leeds 1803 Internal Derangement of the Knee 1938 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” Don O’Donoghue, M.D. Treatment of Injuries to Athletes 1962 The Book that Launched Sports Medicine as a Specialty “The examination of the patient may, of course, often solve the difficulty.” “ Careful, tender but meticulous complete examination of every sprain of the knee” “The decision to operate or not depends on the results of a careful examination” Don O’Donoghue, M.D. Treatment of Injuries to Athletes 1962 A.G. Apley Frank Jobe M.D. Robert Kerlan. M.D. on the physical exam “Making a diagnosis is an art and you need to listen to the patient. But you also have to touch them and examine them and act like you know what you are doing.” The Problem 50 + Named Tests No consensus on accuracy of tests Shrinking Amount of Time to Actually Examine Pts. More Demand for Documentation Game Plan Review the Tests and Supporting Evidence Select Best Tests to Use Develop a Sequence to Smoothly Perform and Repeat an Exam with the Best Possible Accuracy Examination of the Knee History Inspection Palpation Anterior Knee Meniscal Exam Ligamentous Exam History • What • When • Where • How? • About the Patient • Work –Play ‐ Goals Inspection Not Just Knees Gait Hips Musculature Lower Leg Rotation Foot and Ankle Alignment Palpation Effusion Tenderness Peri‐Patella Plica Joint Line Medial Lateral MCL LCL origin/insertion Patellar Tendon Tibial Tuberosity Patello- Femoral Joint Goldthwait 1904 Boston Med J • Q angle • Patella Alta • Trochlear dysplasia • Medial Laxity Fairbank 1936 Proc Royal Soc Apprehension Sign Hughston 1968 JBJS • Subluxation of the Patella Insall 1976 JBJS • Chondromalacia Patellae Dr. Hughston Subluxation of the Patella JBJS 1968 Promoted Awareness Don’t Overlook the Anterior Knee Lateral Posture VMO Dystrophy Passive Subluxation Medial Tenderness Patello - Femoral Joint Observation/Inspection • Position ‐ Baja Alta • Quadriceps “Q” Angle • Tracking in Flexion and Extension “J tracking” Patellar Tracking Patello - Femoral Tests • Tilt Test • Glide Test • Grind Test (Clarke’s Sign) Apprehension Test (Fairbank’s Test) Knee Flexed 30◦ Lateral Stress Pos. Test Apprehension P-F Instability “Moving Patellar Apprehension Test” ✔ 2 Parts Flexion with Lateral Stress Flexion with Medial Stress Pos. Test = Apprehension Lateral Only SN 100% NPV 100% Ahmad 2009 AJSM Accuracy 94% Meniscal Exam Meniscal Tests Tenderness or Clicks Pain with Rotation Joint Line Palpation Apley’s Grind Test Bragard Test Bohler Test Steinmann 2nd Test Helfet Test McMurray’s Test Payr’s Test (duck walk) Steinmann 1st Test Blocked Extension Merke’s Test Bounce Test Ege’s Test Knee Jerk Test (Oni) Thessaly Test McGinty Test Med. Lat. Grind Test Allingham 1889 Palpation Joint Line Tenderness “Essential Part of Exam” JLT + Effusion Most Sensitive Test 1889 “Now, however, a change has come over the scene; life is lived at higher pressure, and competition is greater than it used to be; anything that clogs the wheels of life entails on the sufferer loss of health, of time, and of money, incapacitates him from some occupations, and debars him from some pleasures and invigorating sports.” McMurray’s Test T.P. McMurray The Semilunar Cartilages Br Journal of Surgery 1942 ER for medial meniscus IR for lateral meniscus “This method of evaluation is of little value if the lesion is anterior to midline” Positive Test: Painful Click or Snap Medial – Lateral or Anderson’s Grind Test Anderson & Lipscomb AJSM 1986 Adding Circumduction Pos = “grinding sensation” False positives Infrequent Mid Body Meniscus Tears Bounce Test “Bounce Home Test” Allingham Internal Derangements of the Knee Joint London 1889 Bucket Handle and Anterior Horn Tears Apleys’ Test Apley A.G. JBJS 1947 The Diagnosis of Meniscus Injuries‐ New Methods Prone Compression + Rotation Pain = Meniscus Tear Distraction + Rotation Pain = Ligament Sprain Thessaly Test aka “Disco Test” A New Clinical Test for Early Clinical Detection of Meniscal Teas Karachalios , et al JBJS 2005 Performed @ 20° Flexion Accuracy 94% 96% Evidence for Meniscal Tests • Solomon ‐ JAMA 2001 ‐ Meniscus LR+ <3 Combination is recommended • Rob ‐ J Fam Prac 2001 –Meta Analysis McMurray’s highest PPV • Malanga ‐ Arch Phys Med Rehab 2003 McMurray’s high SP JLT high SN • Bartz CORR 2007 –Review “no constant and pathognomonic sign exists” • Konan ‐ Knee Surg Sport Arth 2009 ‐ JLT best plus Thessaly / McMurray’s Better ‐ 95% • Lowery ‐ Arthroscopy 2006 ‐ Composite Score 5 tests‐ (includes history) PPV 92% Evidence Summary Meniscal Tests • Exam plus History improves Accuracy • Experience with the tests improved accuracy • All tests trended less accurate with concomitant ligamentous injuries • Tests were more accurate in young pts and acute injuries, less so with degenerative knees • Combinations including JLT were best: McMurray’s Grind Test Bounce Home History Ligamentous Exam George Noulis 1875 Paris “Sprains of the Knee” Abdxn Rocking First description of drawer test ‐ Lachman’s? Hey Groves 1917 London “On passive manipulation.. the diagnosis is a matter of considerable certainty” Sir Robt Jones 1923 London “The diagnosis therefore of a ruptured crucial ligament should not be very difficult” A. Thorndike 1938 Harvard “marked increase in the ant‐post mobility suggests injury to the crucial ligaments” O’Donoghue 1950s MCL Medial Collateral Ligament Pt. Supine Apply Valgus Stress 30 degrees 0 degrees Grades I‐III Marshall 1978 Compare both Sides LCL Lateral Collateral Ligament Pt. Supine Apply Varus Stress 30 degrees 0 degrees Laxity @ 0 = PLC +/‐ Cruciate Anterior Drawer Test Knee Flexed 90 ° Tibia in Neutral Endpoint Firm –Soft ‐ Absent A = Firm B = Soft Accuracy in Acute Injuries Poor “Doorstop effect“ of post. meniscus Lachman’s Test “Clinical Diagnosis of ACL Instability in the Athlete” Torg, et al, AJSM 1976 Eliminates: pain with flexion hamstring spasm “doorstop” effect Accuracy 95% Lachman’s Test Patient Supine Relaxed Flexion ‐ 30 Degrees Tibia Neutral R/O Posterior Subluxation Grading: I ‐ II – III A ‐ Firm B‐ Soft ACL Lelli Test aka Lever Sign Test Knee Surg Sport Trauma Arthros 2016 Bigger Patients Smaller Examiner Accurate for Acute and Partial Rotatory Instabilities ALRI PLRI Pivot Shift (MacIntosh) Dial Test Jerk Test Hughston PL Ext Rot Test Losee Test Ext Rot Recurvatum Side Lying Test Slocum Postero Lateral Drawer Flexion Rot Drawer Noyes Reverse Pivot Shift Test AMRI Slocum Test PMRI Larson Pivot Shift Test Galway, MacIntosh 1980 Clin Ortho Sign and Symptom Extension Int Rot. Valgus Slow Flexion Reduction (shift) @30‐40 PCL Posterior Instability PCL Primary Posterior Restraint Twice as strong as ACL AL Bundle 80% PLC injuries seen in 60% of PCL injuries Posterior Drawer Posterior Sag Test Quadriceps Active Test History First written PE “sign” Posterior Sag Sign Thorndike 1938 PCL Post SAG Test Static Test Thorndike 80% Sensitive 100% Specific Supine Knees at 90° Feet flat on Table Relax Quadriceps Observe from Side PCL Quadriceps Active Daniel JBJS 1988 Supine ‐ Knee at 90° Feet flat on table Ask to slide foot forward > 2mm anterior motion = Pos Test PCL Posterior Drawer Most Sensitive Test for Isolated PCL 90% Sensitive 99% Specific Tibial plateau 1 cm Anterior to MFC Endpoint Not as reliable as Translation PCL vs PLC Post-Lat Rotatory Drawer Hughston Norwood 1980 Externally rotate the foot 15 deg Compare to Neutral Rotation Posterior Force thru Tibia Key: Rotatory motion vs straight translation PLC = ↑ rotaon in ER PCL = ↑ translaon Posterolateral Corner Dial Test Prone or Supine Knees Flexed 30◦ 90◦ “Dial” feet externally > 15◦ difference = positive test Posterolateral Corner Ext. Rot. Recurvatum Test COMPARE TO THE OPPOSITE SIDE Hyperextension Tibial Ext Rotation Knee Varus Alignment Other Wilson’s Test OCD Lesions Complete Knee Exam History ‐ Inspection ‐ Palpation ‐ ROM P F J ‐ Position‐ Tracking‐ Palpation Tilt ‐ Glide ‐ Apprehension Meniscal ‐ JLT ‐ McMurray ‐ Grind ‐ Bounce MCL /LCL ‐ Stress tests @ 30 deg and 0 ACL /PCL ‐ Lachman – Pivot Shift Drawer Ant / Post SAG (QAT) Dial Ext Rot Recurv. PLRot Drawer OTHER ‐ Wilson’s, etc., .