MusculoskeletalCurriculum

History & Exam of the Injured

Knee

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Goal

Learn a standardized, evidence-based history and physical examination of patients with knee injuries

WHICH WILL:

Enable family medicine resident physicians to accurately diagnose common knee problems throughout the full age spectrum of patients seen in family medicine

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Competency-Based Objectives Patient care – focused history and exam

Professionalism – respect, compassion

Interpersonal and communication skills – differential diagnosis

Medical knowledge base – anatomy, injury mechanisms

Systems based practice – accuracy, time-efficiency

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Assessing a knee injury

Components of the assessment include Focused history Attentive physical examination Thoughtfully ordered tests/studies (for future

discussion)

Focused History

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Focused History Questions

Onset of Pain Date of injury Character/nature of pain

Location of pain* Anterior Medial Lateral Posterior

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Focused History Questions2

Mechanism of Injury – helps predict injured structure

Contact or noncontact injury?*

If contact, what part of the knee was contacted? Anterior blow? Valgus force? Varus force?

Was foot of affected knee planted on the ground?**

Valgus alignment = distal segment deviates lateral with respect to proximal segment. Patellas Touch

http://moon.ouhsc.edu/dthompso/namics/varus.gif

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Focused History Questions3

Injury-Associated Events Pop heard or felt?

Swelling after injury (immediate vs delayed)

Catching / Locking

Buckling / Instability (“giving way”)

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Instability - Example

http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocation.JPG

Patellar dislocation

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Focused History Questions4

Degree of Immediate Dysfunction

|------------------------|Unable to Antalgic Continued

Ambulate Gait* to Participate

History of Prior Knee Injuries or Surgeries

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Historical Clues to Knee Injury DiagnosisNoncontact injury with “pop” ACL tear

Contact injury with “pop” MCL or LCL tear, meniscus tear, fracture

Acute swelling ACL tear, fracture, knee dislocation

Lateral blow to the knee MCL tear

Medial blow to the knee LCL tear

Knee “gave out” or “buckled” ACL tear, patellar dislocation

Fall onto a flexed knee PCL tear

Physical Exam

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Physical Exam - General

Develop a standard routine Alleviate the patient's fears

GENERAL STEPSInspection

Palpation

Range of motion

Strength testing

Special tests

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Physical Exam - Exposure

Adequate exposure - groin to toes bilaterally

Examine in supine position Compare knees

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Observe – Static Alignment Patient stands facing examiner with

feet shoulder width apart Ankles, subtalar joints – pronation, supination Feet – pes planus, pes cavus

(http://www.steenwyk.com/pronsup.htm)

Pes planus Pes cavus

(http://www.arc.org.uk/about_arth/booklets/6012/images/6012_1.gif)

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Patient then brings medial aspects of knees and ankles in contact Knees – genu valgum

(I), genu varum (II)

Observe – Static Alignment

(http://www.orthoseek.com/articles/img/bowl1.gif)

Genu valgum Genu varum

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Observe – Dynamic Alignment

Pronation/Supination may be enhanced with ambulation

Antalgic gait indicates significant problem (anti = against, algic = pain)

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Inspect Knee

Warmth Erythema Effusion*

Evidence of local traumaAbrasionsContusionsLacerations

Patella positionMuscle atrophy

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Inspect Knee-Related Muscles

Quadriceps atrophy Long-standing problem

Vastus medialis atrophy

After surgery

http://www.neuro.wustl.edu/neuromuscular/pics/people/patients/Hands/ibmquadatrsm.jpg

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Normal Knee – Anterior, Extended

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Surface Anatomy - Anterior, Extended

Patella

Hollow

Indented

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Normal Knee – Anterior, Flexed

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Surface Anatomy - Anterior, Flexed

Head OfFibula

Patella

TibialTuberosity

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Palpation – Anterior*Patella:

Lateral and Medial Patellar Facets

Superior AndInferior Patellar Facets

Patellar Tendon**

Lateral Fat PadMedial Fat Pat

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Surface Anatomy - Medial

Medial FemoralCondyle

Patella

JointLine

MedialTibial Condyle

TibialTuberosity

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Palpation - Medial

Medial Collateral Ligament (MCL)*

Pes anserine bursa**

Medial joint line

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Surface Anatomy – Lateral

Patella

Head OfFibula

TibialTuberosity

Quadriceps

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Palpation – Lateral*

Lateral joint line

Lateral Collateral Ligament (LCL)**

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Palpation - Posterior

Popliteal fossa

Abnormal bulges Popliteal artery aneurysm Popliteal thrombophlebitis Baker’s cyst

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Range Of Motion Testing Extension Flexion

0º 135º

Describe loss of degrees of extension Example: “lacks 5 degrees of

extension,” or “extension = minus 5 degrees”

Locking* = patient unable to fully extend or flex knee

due to a mechanical blockage in the knee (i.e., loose body, bucket-handle meniscus tear)

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Special Tests – Anterior Knee Pain

Patellar apprehension test*

Patellofemoral grind test**

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Special Tests - Ligaments

Assess stability of 4 knee ligaments via applied stresses*

Anterior CruciatePosteriorCruciate

Lateral Collateral

Medial Collateral

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Stress Testing of Ligaments2

Use a standard exam routine Direct, gentle pressure No sudden forces

Abnormal test 1. Excessive motion = laxity

What is NORMAL motion?*

2. Soft/mushy end point**

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Collateral Ligament Assessment

Patient and Examiner Position*

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Valgus Stress Test for MCL*

Note Direction Of Forces

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Video of Valgus Stress Test

Click on image for video

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Varus Stress Test for LCL*

Note direction of forces

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Video of Varus Stress Test

Click on image for video

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Lachman’s Test* Patient Position Physician hand placement

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Lachman’s Test2

View from lateral aspect*

Note direction of forces

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Video of Lachman’s Test

Click on image for video

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Alternate Lachman’s Test

Click on image for video

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Anterior Drawer Test for ACL

Physician Position & Movements* Patient Position

Note direction of forces

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Posterior Drawer Testing- PCL*

Note direction of forces

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Assess Meniscus – Knee Flexion

Most sensitive test is full flexion* Examiner passively flexes the knee or has patient

perform a full two-legged squat to test for meniscal injury

Joint line tenderness** Flexion of the knee enhances palpation of the

anterior half of each meniscus

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No Evidence to Support

Pivot-Shift* - for ACL tear

McMurray Testing**- for meniscus tears