Examination of the Knee

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Examination of the Knee

• Thursday SM Conference
• August 30, 2007

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Exam Settings

• Sideline Exam (on the field triage)
• Training room (post game eval)
• Office/clinic Exam (delayed detailed)

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Sideline ExamPurpose determine disposition

• Transfer (severe injury)
• Hold out (mild moderate)
• Observe re-examine
• Provide first aide
• Return to action (mild ? no injury?)

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Sideline Exam Routine

• Determine mechanism
• Point of maximum tenderness
• Maneuver producing most pain
• Determine severity of damage

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Case Presentation

• 22 year old collegiate wrestler
• Contact injury to left knee
• Medial-sided knee pain

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• Mechanism ?
• Foot planted
• Outside force
• Pain pop

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Sideline Exam

• Pain on inside

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Medial Pain(Differential Diagnoses)

• Medial Collateral Ligament sprain
• Hamstring strain
• Gastroc strain
• Medial Meniscus tear

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First find Joint line
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Maximum Tenderness?

• Pain on inside
• Tender over MCL

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Most Painful maneuver?

• Straight Valgus?
• Straight
• 30 degrees
• External rotation?

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Sprain Severity?

• Classify by laxity
• Best exam technique
• One-handed
• Two handed

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Check both sides!

• Laxity normal ???
• Plastic man
• Post exercise

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Anterior Drawer at 20-30 degreesModified
Lachmans
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Exam Settings

• Sideline Exam (on the field triage)
• Training room (post game eval)
• Office/clinic Exam

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Two handed technique

• Trap ankle on Iliac crest
• Both hands on joint line
• Palpate both joint lines

Stress X-ray
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Sprains (ligaments)
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Sprains (ligaments)
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Sprains (ligaments)
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Hughston Laxity Classification

• Grade I 1-4 mm laxity
• Grade II 5-9 mm laxity
• Grade III gt10 mm laxity (soft endpoint)
• Hughston JC, Andrews JR, Cross MJ, Moschi A
  Classification of knee ligament instabilities.
  Part I. The medial compartment and cruciate
  ligaments.
• J Bone Joint Surg Am 58159-172, 197

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Two handed technique

• Trap ankle on Iliac crest
• Both hands on joint line
• Palpate both joint lines

Stress X-ray
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Two handed technique
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Collegiate football Severity vs. Return

• Grade I 10.6 days
• Grade II 19.5 days
• Derscheid, G.L. and J.G. Garrick.
• MCL injuries in football Non-operative
  management of grade I and grade II sprains.
• Am J Sports Med, 1981. 9(6) p. 365-8.

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Sideline estimate(Crowley-Albright 30
consecutive FB cases)

• 1 mm 1 week
• 2 mm 2 weeks
• 3 mm 3 weeks
• 6 mm 6 weeks

millimeters weeks
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Time Loss From Sport

• Severity of injury
• Compliance??

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Exam Settings

• Sideline Exam (on the field triage)
• Training room (post game eval)
• Office/clinic Exam

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Office Exam

• What is important about the MCL exam?
• Knee stability in full extension

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Knee HemarthrosisDifferential Diagnosis

• ACL 70
• Meniscus 50
• Fracture 20
• Patellar dislocation
• PCL

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Value of MRI?

• When should an MRI be done?
• When knowledge of location of injury might
  influence treatment
• When additional injury is suspected
• Instability at full extension should increase
  suspicion of cruciate injury
• Mazzocca, A.D., et al., Valgus medial collateral
  ligament rupture causes concomitant loading and
  damage of the anterior cruciate ligament.
• J Knee Surg, 2003. 16(3) p. 148-51.

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Location MCL Tissue damage

• Proximal ruptures heal more quickly than distal
  but have more stiffness
• Complete ruptures can displace into the joint
• Damage over entire ligament associated with
  persistent laxity after non-operative treatment
• Nakamura, N., S. Horibe, et al. (2003). "Acute
  grade III MCL injury of the knee associated with
  ACL tear. usefulness of MRI in determining
  treatment regimen."
• Am J Sports Med 31(2) 261-7.

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Grade III Gross instability Laxity at full ext
(no endpoint)

• Indicates complete rupture of MCL
• Evaluate posteromedial capsule
• Evaluate for cruciate injury
• ACL
• PCL
• Evaluate for Patellar Dislocation

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Pivot shift techniques

• Re-entry tests
• MacIntosh
• Hughston Jerk
• Exit tests
• Losee (5 tests)
• Slocum
• Low profile

Slocum's pivot test
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The Pivot-ShiftLow Profile Technique

• exit type pivot (in-to-out of place)
• No valgus
• Limit arc to last 20 degrees

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Losee Tests

• See video

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Active Quad Self Induction of Pivot Shift
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LCL??? or MCL???
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Reverse pivot

• Ask patient In or out?

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Meniscus tears

• Joint line tenderness
• Most sensitive but least specific (Fu)
• Squat and duck walk test
• McMurray' s test
• Modified McMurray' s test
• Most sensitive but least sensitive
• Appleys test
• Modified Appleys test
• Full Extension??
• Pain anterior joint line

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Modified McMurray' s test
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Displaced Meniscus?(bucket-handle tear)

• Lacks full extension
• No screw home
• Pain anterior joint line
• Rotation affects degree of pain
• Lacks full flexion
• Rotation affects degree of pain
• Rotation OK in mid range flexion

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Anterior knee pain

• Osgood Schlatter' s
• Jumpers knee
• P-F Chondromalacia
• Synovitis (Plica?)
• P-F instability