Garry W' K' Ho, M'D'

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History Physical Examination of the Knee
Garry W. K. Ho, M.D. VCU / Fairfax Family
Practice - Sports Medicine Fellow May 2007
Loosely adapted from C.S. Nasin, MD The Knee
Exam
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Objectives

• Review pertinent clinical anatomy of the knee
• Review differential diagnosis of knee complaints
• Review clinical history and physical examination
  of the knee
• Common knee injuries findings

Shaun Livingston
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Anatomy - Osteology
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Anatomy - Osteology

• Femur
• Medial lateral
• Condyles
• Epicondyles
• Trochlear groove
• Intercondylar notch
• Patella
• Superior pole (base)
• Inferior pole (apex)
• Medial lateral facets

• Tibia
• Medial lateral
• Condyles
• Gerdys tubercle
• Pes anserine area
• Tibial tuberosity
• Tibial plateau
• Tibial spines
• Fibula
• Head
• Neck

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Anatomy Major Ligaments Tendons

• Quadriceps tendon
• Patellar tendon
• Medial lateral patellar retinaculum
• Medial collateral ligament (MCL)
• Lateral collateral ligament (LCL)
• Iliotibial tract (IT band)
• Anterior cruciate ligament (ACL)
• Posterior cruciate ligament (PCL)

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Anatomy Menisci of the Knee

• Medial meniscus
• Lateral meniscus
• Meniscal ligaments
• Functions of the menisci
• Meniscal zones
• White-white
• Red-white
• Red-red

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Anatomy Popliteal Area

• Popliteal fossa
• Popliteal vessels
• Tibial nerve
• Common peroneal nerve
• Gastrocnemius
• Medial lateral heads
• Hamstrings
• Semitendinosus
• Semimembranosus
• Biceps femoris
• Popliteal (Baker) cysts

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Anatomy Bursae about the Knee
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Differential Diagnosis

• Osteoarthritis / Chondromalacia
• Inflammatory arthritis
• Meniscal tears
• Avascular necrosis
• Fractures
• Supracondylar femur
• Patellar
• Tibial plateau
• Osteochondral lesions
• Dislocations / subluxations
• Tibio-femoral
• Patello-femoral
• Patellofemoral Pain syndrome
• Plica syndrome
• Apophysitis
• Osgood-Schlatter
• Sinding-Larsen Johanssen
• Tendonosis
• Quadriceps

• Muscle and tendon strains
• Myotendinous contracture syndromes
• Iliotibial tract (band)
• Hamstring
• Bursitis
• Supra-, Pre-, Infra- patellar
• IT band, pes anserine
• Myositis ossificans / Heterotopic ossification
• Nerve entrapment
• Common peroneal
• Infrapatellar nerve
• Tibial nerve
• Vascular diseases
• Peripheral vascular disease
• Neuro-claudication
• Referred pain
• Intraartivular hip disease DDD
• Slipped Capital Femoral Epiphysis
• Radiculopathy

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Clinical History

• Mechanism of Injury ? Able to continue play?

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Clinical History

• Location of pain
• Onset Timing
• Acute vs. Chronic
• Traumatic vs. Overuse
• Characterize pain
• Night pain
• Morning stiffness
• Weakness
• Deformity
• Instability / Giving Way
• Locking / Clicking / Popping /
• Catching / Clunking
• Alleviating / Exacerbating Factors
• Previous treatments
• Sport Exercise / Training equipment habits
• Occupation
• History of prior injury
• Other symptoms (ROS)

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Physical Examination

• Observation
• Undress waist ? down
• Shorts
• Palpation
• Active passive ROM
• Special tests
• Extensor mechanism, effusions, anterior knee
• ACL PCL
• MCL LCL
• Meniscal tests
• Contracture testing

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Observation

• Undress waist ? down
• Gown, drape, or shorts
• Gait pattern
• Deformity
• Ecchymosis / Abrasion
• Erythema / Edema
• Joint Effusion (more later)
• Atrophy
• Limb length discrepancy
• Foot ankle morphology kinematics

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Surface Anatomy Palpation - Anterior
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Surface Anatomy Palpation - Medial
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Surface Anatomy Palpation - Lateral
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Surface Anatomy Palpation - Posterior
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Range of Motion

• Passive
• Active ROM
• Flexion 135
• Extension 0 to -5
• Internal rotation 10
• External rotation 10

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Intra-articular Effusions

• Large effusions
• Fairly obvious on inspection
• Moderate-large effusions
• Patellar ballottement
• Smaller effusions
• Milk effusion fluid
• Suprapatellar pouch ? distally to side ? tap
• Look feel for fluid wave

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Extensor Mechanism Integrity

• Straight-leg Raise
• Quadriceps tendon
• Patella
• Patellar tendon

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Anterior Knee Patellofemoral Joint

• Patellar instability
• Patellar Apprehension
• Lateral patellar displacement
• ? patient apprehension
• or guarding
• Patellar Glide
• Knee at 30 deg flexion
• Medial lateral patellar displacement
• Measured in quadrants
• Normal 1-2 quadrants

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Anterior Knee Patellofemoral Joint

• Patellar instability
• Patellar tracking
• Patellofemoral pain
• Palpation of patellar facets
• Glide and lift patella medially laterally
• Palpate undersurface of patella for tenderness

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Anterior Knee Patellofemoral Joint

• Patellofemoral pain
• Patellar Grind Test
• AKA Tether test
• Knee 10 deg flexion
• Glide patella distally, and firmly compress
  patella against trochlear groove
• Active quadriceps contraction ? pain

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Anterior Stability - ACL Injury

• Symptoms
• Pain, audible pop
• Unable to RTP
• Swelling within hours
• Symptoms of instability
• Mechanism of Injury
• 80 - Non-contact
• Plant, deceleration, pivot on a planted foot
• Soccer
• Femur ? ER on fixed tibia
• Valgus load
• Basketball
• Hyperextension
• IR of tibia
• Contact mechanism

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Anterior Stability - ACL Injury

• Anterior Drawer Test
• Knee flexed to 90 degrees
• Anteriorly translate tibia on femur
• Watch feel for amount of translation end
  point
• Lachman Test
• Knee flexed to 15-30 degrees
• Stabilize distal femur
• Anteriorly translate tibia on femur
• Watch feel for amount of translation end
  point
• Other Tests
• Pivot-Shift Test, etc

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Posterior Stability - PCL Injury

• Symptoms
• Often vague
• Insecure feeling, possibly symptoms of
  instability
• Diffuse aching knee pain
• Difficulty climbing stairs
• Mechanism of Injury
• Dashboard injury
• Posteriorly directed force
• ? anterior aspect of
• flexed knee
• Falling onto flexed knee
• With foot plantar flexed

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Posterior Stability - PCL Injury

• Posterior Drawer Test
• Knee flexed to 90 degrees
• Posteriorly translate tibia on femur
• Watch feel for amount of translation end
  point
• Sag Sign
• Knees flexed, quads relaxed
• ? compare both sides
• Look for tibial posterior sag relative to femur
• Quad-Active Test
• Knee flexed hamstrings fully relaxed
• Slide foot along table (quad active)
• Observe for anterior relocation

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Valgus Stability - MCL Injury

• Symptoms
• /- medial swelling
• Medial pain TTP
• /- symptoms of instability
• /- lateral ecchymosis
• Mechanism of Injury
• Direct blow to lateral knee
• ? valgus stress
• Plant twist
• ? valgus stress
• Valgus stress to knee on planted leg)
• Unhappy Triad

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Valgus Stability - MCL Injury

• Valgus Stress Testing
• Knee flexed to 30 degrees
• Relax ACL/PCL joint capsule
• Valgus stress applied to knee
• Look and feel for translation and endpoint
• Compare to uninjured side
• May repeat with knee in full extension

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Varus Stability - LCL Injury

• Varus Stress Testing
• Same test as valgus stress testing
• Except applying a varus stress instead
• LCL, IT band, PLC are tested

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Meniscal Injuries

• Symptoms
• Pain
• Medial
• Lateral
• Poorly localized
• Pain usually worse with squatting stairs
• Popping, catching, locking, or buckling
• Delayed effusion
• Unless peripheral tear
• Mechanism of Injury
• Non-contact cutting, deceleration, hyper-flexion
• Poorly landing from jump
• Medial gt Lateral
• Unhappy triad

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Meniscal Injuries

• Joint line tenderness
• Medial or lateral
• Squat duck-walk
• No pain significant meniscal tear unlikely
• McMurray Wilson Tests
• Medial meniscus
• Flexed knee
• Apply valgus external rotation stress
• ? Extend knee
• Lateral meniscus
• Flexed knee
• Apply varus internal rotation stress
• ? Extend knee
• Positive painful click

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Meniscal Injuries

• Apley meniscal compression distraction tests

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Indications Ottawa Knee Rules

• Stiell et al. - Ann Emerg Med 1995
• Ottawa Knee Rules
• Age 55 or older
• Isolated tenderness at patella (no bony
  tenderness of knee other than patella)
• Tenderness at head of fibula
• Inability to flex knee to 90 degrees
• Patient unable to bear weight for four steps
  immediately and in the emergency department or
  office
• Sensitivity 100 ? 97
• NPV 100
• Specificity 49 ? 27

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Muscle Contracture Testing

• Musculotendinous tightness
• Predispose to injury
• Hamstring
• IT Band
• Hip flexors

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Summary

• Know your anatomy and injury patterns
• Know your differential
• diagnoses
• You diagnose what you know
• Get a detailed history
• Stay organized
• Know why youre doing
• an exam
• Follow-up, follow-up, follow-up

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Questions ?
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Thanks !
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Hamstring Contracture Testing

• Popliteal angle
• Hamstring contractures
• Patient supine
• Hip flexed to 90
• Passively extend knee
• ? until resistance encountered
• Normal is lt 40

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Hip Flexion Contracture Testing

• Modified Thomas Test

• Patient sitting on edge or end of exam table
• Holding unaffected knee in flexion
• Affected hip and knee relaxed
• ? Patient instructed to freely / swiftly lie
  back, holding unaffected knee in flexion
• Positive test affected hip and knee pops up
  into flexion
• May be more sensitive

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IT Band Contracture - Obers Test

• Lateral decubitus with testing side up, testing
  knee flexed
• Adduct and fully flex hip ? Abduct, externally
  rotate, extend hip
• Maintain this hip position
• Slowly release support against gravity from leg,
  allowing gravity to take leg towards

• Positive test for IT band / TFL contracture
• Leg remains abducted or fails to return to
  adducted position despite releasing leg
• Positive test for gluteus medius contracture
• Test positive with hip in neutral flexion

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Pivot Shift Test

• Test for rotational instability in ACL tears
• Knee in extension
• Secure lateral leg near knee
• Secure medial leg just distal to other hand
• Apply internal rotational gentle valgus force
  to the extended knee
• Then bring knee ? flexion
• Observe for clunk
• Reduction of the anterolaterally subluxed tibia
  on femur by IT band
• Usually at about 30 flexion

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Posterolateral Corner

• IT Band
• Biceps femoris tendon
• LCL
• Posterolateral joint capsule
• Lateral meniscus
• Lateral coronary ligament
• Popliteus
• Arcuate ligament complex
• Arcuate ligament
• Popliteofibular ligament
• Fabellofibular ligament

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Posterolateral Corner Injuries

• More significant injury
• Posterolateral instability
• Rotational instability
• Associated with other ligamentous injuries
• Atraumatic, chronic laxity vs. traumatic injury
• Very poor prognosis without prompt surgical
  repair
• Often missed ? need for high index of suspicion
• Subtle exam findings
• Hyperextension
• External Rotation Recurvatum Test
• Posterolateral Drawer
• Reverse Pivot Shift Test
• Dial Test

Easily Missed Diagnosis Ahead
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Hyperextension External Rotation Recurvatum
Test

• Supine position
• Grasp great toes of both feet
• Lifts both LE off exam table
• Compare both knees
• Assess for increased knee
• Extension ? hyperextension or recurvatum
• External rotation of tibia
• Varus
• Positive ? severe ligament injury
• Combined PLC / or ACL and PCL injury

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Posterolateral Drawer

• Similar to posterior drawer
• Knee flexed to 90
• Foot rotated 15 - 20
• Apply posterior external rotational stress
• Assess for posterolateral translation endpoint
  of tibia on femur
• Positive test ? presence and severity

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Reverse Pivot Shift Test

• Basically the pivot shift done in reverse
• Knee flexed to 60- 70
• Secures foot / ankle
• Secure lateral leg near knee
• Apply external rotational force to the flexed
  knee
• Then bring knee towards full extension
• Observe for clunk
• Reduction of posterolateral subluxation of tibia
  on femur by IT band

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Dial Test (AKA Thigh-Foot Angle)

• Supine, seated, or prone position
• External rotation
• at 30 90 degrees
• Abnormal if
• gt10 degrees (absolute)
• gt5 degree side to
• side difference
• Compare to
• contralateral side

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Review of Evidence ACL
(Jackson JL, et al.)

• Lachman Test Sens 87 Spec 93
• Anterior Drawer Sens 48 Spec 87
• Pivot Shift Test Sens 61 Spec 97

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Review of Evidence - Meniscus
(Jackson JL, et al.)

• Joint Line Tenderness Sens 76 Spec 29
• McMurray Test Sens 52 Spec 97

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Review of Evidence - General
(Ebell MH.)
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Sample Management Algorithm