Knee Injury and Examination

Dr James Thing

Sport and Exercise Medicine Consultant

Connect Physical Health

Objectives

• Discuss common knee pathologies seen in General Practice

• Basic assessment and management principles

• When to refer

• Cases

What to ask in the history?

• How long has the pain been present for?

• Any obvious triggers or specific incidents?

• If specific incident – what was the exact mechanism?

• Where is the pain located?

• Type of pain?

• When does pain occur – during sporting/non-sporting activity?

• Swelling – when did it occur – immediate/delayed/intermittent?

• Any giving way or locking?

• Previous injury, operation or problems?

• Impact on job/life/sport at present – functional ability?

• Current management so far?

Basic Assessment &

Management Principles

• Full history and examination

• Consider the level of disability

• Consider the age of the injury

• Consider need for referral

• Consider need for XR

Ottawa Knee Rules

XR needed if –

• <18 or >55 years old

• Tender fibular head or patellar

• Inability to flex beyond 90°

• Inability to WB more than 4 steps now or at time of injury

When to refer

• Immediate haemarthrosis/swelling - caused by……..

i) Peripheral meniscal tear (red zone)

ii) Cruciate ligament tear

iii) Fracture – patella/femur/tibia

iv) Patellar dislocation

………….requires XR and assessment in hospital

• Grossly reduced ROM or inability to WB after initial period of swelling has

settled

• Acute locking – unable to flex or extend fully due to mechanical block

• Persistent symptoms beyond initial period

Case 1

• 45-year-old sedentary accountant slipped on ice, twisting R knee 7 days

ago

• Able to stand and part WB at the time. No initial swelling but some noted by

evening

• Now swelling settling, pain improving, tender along medial JL, tender in

extreme of flexion with clicking (McMurray’s +ve)

• Diagnosis?

• ?Meniscal injury

Case 1 management

• PRICE or POLICE (Optimal Loading)

• XR? – probably won’t add much, Ottawa Knee Rules

• Conservative v Surgical approach – depends on level of

disability/job/activity level

• MRI? – depends on certainty of clinical diagnosis and likelihood of surgery

Conservative v Surgical

Conservative Surgical

No specific injury Severe twisting injury

Able to WB Not improving with conservative mx

Minimal swelling Associated injury i.e. ACL tear

Full ROM Locked knee or severely restricted ROM

Pain on McMurray’s at extreme ROM only McMurray’s pain on minimal flexion

Adapted from Clinical Sports Medicine, 3rd Edition, Brukner & Khan

Case 1 management

Conservative –

• No further imaging required

• Physiotherapy – regain full ROM, strengthening work

• If not progressing – consider referral

Surgical -

• For large, painful tear +/- acutely locked knee

• MRI pre-arthroscopy to define injury

• Arthroscopy then rehabilitation (physio led)

Case 2

• 67 year old retired dancer

• Gradual onset aching pain in both knees with mild swelling over 2 years

• No locking/GW

• Worse in cold weather

• Causing problems with walking long distances

• Keen for something to be done……

• …….but has a fear of surgery

Case 2

• OE – bilateral crepitus, mild effusion

• Restriction in flexion bilat. to 100°, loss of end 10° extension

• Wasted quads, 4/5 power

• McMurray’s –ve, No ligament concerns

• Diagnosis?

• ?OA

• XR…..

Case 2

Osteophyte

Subchondral sclerosis

Joint Space Narrowing

Case 2

• Management options –

– Exercise/weight loss

– Physio/Rehab – ROM & strength work

– Oral analgesia

– Glucosamine/Chondroitin

– Topical options – NSAIDs, capsaicin, flexiseq

– Intra-articular – Steroids, hyaluronic acid, PRP

Case 2

• Steroids –

– x3 per year, reduced efficacy with time

– caution with warfarin/insulin

– supported by NICE

• Hyaluronic Acid –

– Can be useful for mild – mod OA

– Not supported by NICE (funding issues)

Case 3 - PFPS

• 25 year old office worker

• Training for London Marathon

• Pain over R anterior knee

• Worse with stairs/sitting for long periods

• Pain tends to warm up during runs but painful following day

• No locking, swelling

• Occ sensation of giving way on stairs

Case 3

• Examination

– Full ROM/Normal power

– No effusion

– “knock knees” (Genu Valgus)

– Flat feet R>L

– SL squat – exacerbates knocked knee position & poor control (wobbly)

– Clarke’s test +ve on R, -ve on L

– Otherwise NAD

– ?Diagnosis

– ?PFPS

Case 3

• PFPS

– Lateralisation of patella in femoral groove

– Pain over antero-lat knee as result

– Clinical diagnosis, no imaging needed

– Rx – physio/rehab - centralising the patella

– Stretch ‘tight’ lateral structures, i.e. ITB

– Strengthen ‘weak’ medial structures, i.e. VMO (glutes)

– Consider podiatry if pes planus or pronated foot posn

Case 4

• 22 year old female skier, landed awkwardly, catching inside edge of ski and

twisting R knee

• Immediate pain and swelling noted

• Unable to WB, transported to hospital

• Waited for 3 hrs to be seen then gave up and struggled back to UK

• Seen 2 days later – partial WB, swollen right knee, tender globally, unable

to formally assess as too tender

• ?Diagnosis

• ?ACL tear

Case 4 management

• Clearly serious injury

• Needs XR, analgesia, expert advice

• Referral to A&E or Fracture clinic

• Immobilise with cricket pad splint (A&E)

• Will most likely need MRI +/- arthroscopy if meniscal damage or considering

reconstruction

• Who to reconstruct? – Conservative v Surgical

Conservative v Surgical

guidelines

Factor Conservative Surgical

Age Older Younger

Degree of instability Stable “Gives way”

Associated injury None Meniscus/MCL

Pivoting sport No Yes

Occupation Sedentary – i.e. desk job Active – i.e. fireman

Time/Cost of surgery Not prepared to put time into rehab

Committed to full rehab program

Adapted from Clinical Sports Medicine, 3rd Edition, Brukner & Khan

Take Home Messages

• Consider functional impact on patient

• Most conditions can be managed conservatively

• Ottawa Knee Rules

• Refer if –

– acutely locked

– immediate haemarthrosis

– fail to respond to conservative Rx

Examination Skills

• Look - front, side & back

walking, standing & supine

• Feel - tenderness, effusion & crepitus

• Move - active, passive & resisted

• Special Tests

Examination Skills

Look –

• Expose from upper thigh

• Front, side & back

• Walking, standing & supine

• Swelling

• Bruising

• Deformity

• Scars

• Biomechanics – genu valgus/varus

Examination Skills

Feel –

• For tenderness, effusion, crepitus

• Tibial tuberosity

• Follow patella tendon to distal pole of patella

• Entire patella, suprapatella & Hoffa’s fat pad

• Medial and Lateral joint lines

• Medial and Lateral collateral ligaments

• Hamstring/Gastrocnemius tendons/popliteal fossa

• Pes anserinus

Examination Skills

Move –

• Flexion (140°)/Extension (-5°)

• Active – compare good side to bad side

• Passive – look for end range, pain and ROM

• Resisted – reduced with muscle deficit and pain inhibition

Examination Skills

Special Tests –

• Patella apprehension test/Clarke’s test

• Sweep/Patella tap test

• MCL/LCL

• ACL – Lachman/Anterior drawer

• PCL – Posterior drawer

• Menisci – McMurray’s

Examination Skills - Practical

Look –

• Expose from waist

• Front, side & back

• Walking, standing & supine

• Swelling

• Bruising

• Deformity

• Scars

• Biomechanics – genu valgus/varus

Feel -

• For tenderness, effusion, crepitus

• Tibial tuberosity

• Follow patella tendon to distal pole of patella

• Entire patella, suprapatella & Hoffa’s fat pad

• Medial and Lateral joint lines

• Medial and Lateral collateral ligaments

• Hamstring/Gastrocnemius tendons/popliteal fossa

• Pes anserinus

Move –

• Flexion (140°)/Extension (-5°)

• Active – compare good side to bad side

• Passive – look for end range, pain and ROM

• Resisted – reduced with muscle deficit and pain inhibition.

Special Tests –

• Patella apprehension test

• Sweep/Patella tap test

• MCL/LCL

• ACL – Lachman/Anterior drawer

• PCL – Posterior drawer

• Menisci – McMurray’s