Assessment of the Knee

1
Assessment of the Knee

• Ben Yates MSc, BSc(Hons), FCPod(Surg)

2
Classification

• By anatomical region anterior, posterior,
  medial, lateral
• By intra-articular, extra-articular
• Three joints Patellofemoral, tibiofemoral,
  superior tibiofibula
• Osseous or soft tissue

3
Initial Assessment History

• Injury history
• Pain
• Clicking
• Locking
• Giving way
• Instability
• Swelling

4
Initial Assessment Observation

• Standing/ supine/ walking
• Swelling
• Bruising
• Alignment
• Active and assisted movements of flexion and
  extension

5
Common Symptoms
6
Intra-articular Pathologies (Patellofemoral Joint)

• Chondromalacia patella
• Patellofemoral syndrome
• Excessive Lateral Pressure Syndrome
• Patellofemoral instability

• Osteochondritis
• Patella alta/baja
• Patella stress
• Bi/multipartite patella
• Referred pain

7
Patellofemoral Syndrome

• Commonest joint pathology
• Affects 25-36 of population (Brukner Khan,
  1993 McConnel, 1986)
• 32 of all running injuries (Epperly Fields,
  2001)
• Most commonly seen in adolescent females
• Associated with factors causing early knee
  flexion /or patella maltracking

8
PFS Assessment

• History
• Resisted extension
• Squat (bilateral/ unilateral)
• Clarks test
• Palpation
• 5050 test

• Muscle inflexibility
• Muscle weakness
• Skeletal mal-alignment
• Patella position
• Patella tracking
• Q angle

9
Resisted Extension
10
Clarks Test
11
Direct Palpation
12
5050 Test
13
Patella Tracking
14
Patella Tracking (dynamic)
15
Q Angle
16
Q Angle

• Problems with measurement method
• Strongly associated with PFS and instability
  (Insall et al, 1970,Aglietti et al., 1983,
  Presland Yates 1999)
• Normal angle lt15 degrees
• gt17 degrees maybe pathological

17
Q Angle

• Q angle over 15 degrees increases the relative
  risk of stress fractures of the lower limb by 5.4
  (Wen et al., 1998)
• Rigid functional foot orthoses reduced the Q
  angle in stance by an average 6 degrees (DAmico
  and Rubin, 1986)

18
Patellofemoral Instability

• Intermittent subluxation/ dislocation
• Tests Apprehension, 5050, Patella position and
  tracking
• Symptoms include giving way, medial knee pain

19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
Orthoses and Patellofemoral Syndrome

• Semiflexible functional foot orthoses
  significantly reduced symptoms in 102 subjects
  (Saxena and Haddad, 1998)
• Soft orthoses with medial rearfoot and forefoot
  rubber wedges significantly reduced symptoms (Eng
  and Pierrynowski, 1993)

23
Intra-articular Pathologies (Tibio-femoral Joint)

• OA medial/ lateral compartments
• Osteochondritis
• Osteochondritis dessicans
• Meniscal tears
• Referred pain

• Plica
• Fractured tibial spine
• ACL/PCL tears and ruptures
• Haemarthrosis
• Systemic disease
• Septic arthritis

24
Meniscal Tests

• Apleys Compression
• McMurrays test
• Direct palpation of joint line
• Duck walk
• CT/ MRI
• Arthroscopy

25
Apleys Compression Test
26
McMurrays Test
27
McMurrays Test
28
Palpation of Joint Line
29
(No Transcript)
30
Plicae

• Thickened embryonic fold of synovium
• Incidence 18-60 (Notage et al.,1982 Kegerris et
  al., 1988)
• May complain of clicking and pain
• Most frequently medial to patella (can occur
  anywhere)
• Tests thumbroll, MRI, arthroscopy

31
Thumb roll test
32
Cruciate Pathology

• Grades I, II, III
• ACL often with MCL /or meniscal pathology
• ACL injury commonest cause of prolonged absence
  from sport

33
Gwinn et al., 2000

• ACL injury in men women in US Navy
• Females more prone to ACL injury by
• 1.4 times in common sports
• 4 times in male orientated sports (rugby, soccer)
• 10 times in military training

34
Cruciate Pathology Tests

• Drawer test (ACL/PCL)
• Modified drawer (anteromedial and lateral
  instability)
• Lachman test (ACL)
• Pivot shift test (ACL)

35
Anterior drawer test
36
Modified drawer test
37
Orthoses and intra-articular knee pain

• Valgus wedged insole or shoe significantly
  reduces pain and progression of mild to moderate
  medial compartment OA of the knee (Sasaki and
  Yasuda, 1987)
• ? Affect with ACL pathology by improving stability

38
Extra-articular Pathologies

• Patella tendonitis
• Quadraceps tendonitis
• Sindig Larrson Johansson syndrome
• Bursitis (prepatellar)
• Fat pad impingement
• Coronary ligament strain

• Iliotibial band friction syndrome
• MCL/ LCL pathology
• Fabella
• Hamstring tendonitis
• Popliteus tendonitis
• Referred pain

39
(No Transcript)
40
Patella Tendonitis

• Grades I, II, III, IV
• AKA Jumpers knee
• May co-exist with PFS
• Related to overuse of extensor mechanism
• Tests resisted extension, palpation, patella
  mobilisation, MRI, Ultrasound

41
Witvrouw et al., 2001

• Intrinsic risk factors for patella tendonitis
• Quadraceps and Hamstring inflexibility was the
  most significant factor causing patella tendonitis

42
Direct palpation
43
Collateral Ligament Pathology

• Graded I, II, III
• MCL more commonly injured often with ACL or
  meniscal pathology
• Usually in contact sports or skiing due to
  excessive valgus force
• Tests varus/ valgus stress test

44
Valgus Stress Test
45
Orthoses and Collateral ligament Pathology

• Orthoses may reduce strain on MCL/LCL by varus
  or valgus re-allignment (similar to OA of the
  knee)

46
Iliotibial Band Friction Syndrome (ITBFS)

• Common in sports with repeated knee flexion
• Aggravated by downhill running and ascending
  stairs
• Accounts for 5 of lower limb injuries (Edwards
  et al., 1989)
• Pain felt over lateral femoral epicondyle or
  greater trochanter

47
ITBFS Tests

• Iliotibial band tightness (Obers test)
• Compression of ITB over epicondyle (Noble test)
• MRI
• LA/steroid injection
• Severe cases require surgery

48
Obers Test
49
Noble Test
50
(No Transcript)