Garry W. K. Ho, M.D. - PowerPoint PPT Presentation

1 / 51
About This Presentation
Title:

Garry W. K. Ho, M.D.

Description:

Garry W' K' Ho, M'D' – PowerPoint PPT presentation

Number of Views:69
Avg rating:3.0/5.0
Slides: 52
Provided by: garr7
Category:
Tags: akc | garry | org

less

Transcript and Presenter's Notes

Title: Garry W. K. Ho, M.D.


1
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
2
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
3
Anatomy - Osteology
4
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

5
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)

6
Anatomy Menisci of the Knee
  • Medial meniscus
  • Lateral meniscus
  • Meniscal ligaments
  • Functions of the menisci
  • Meniscal zones
  • White-white
  • Red-white
  • Red-red

7
Anatomy Popliteal Area
  • Popliteal fossa
  • Popliteal vessels
  • Tibial nerve
  • Common peroneal nerve
  • Gastrocnemius
  • Medial lateral heads
  • Hamstrings
  • Semitendinosus
  • Semimembranosus
  • Biceps femoris
  • Popliteal (Baker) cysts

8
Anatomy Bursae about the Knee
9
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

10
Clinical History
  • Mechanism of Injury ? Able to continue play?

11
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)

12
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

13
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

14
Surface Anatomy Palpation - Anterior
15
Surface Anatomy Palpation - Medial
16
Surface Anatomy Palpation - Lateral
17
Surface Anatomy Palpation - Posterior
18
Range of Motion
  • Passive
  • Active ROM
  • Flexion 135
  • Extension 0 to -5
  • Internal rotation 10
  • External rotation 10

19
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

20
Extensor Mechanism Integrity
  • Straight-leg Raise
  • Quadriceps tendon
  • Patella
  • Patellar tendon

21
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

22
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

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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

31
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

32
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

33
Meniscal Injuries
  • Apley meniscal compression distraction tests

34
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

35
Hamstring Contracture Testing
  • Popliteal angle
  • Hamstring contractures
  • Patient supine
  • Hip flexed to 90
  • Passively extend knee
  • ? until resistance encountered
  • Normal is lt 40

36
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

37
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

38
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

39
Questions ?
40
Thanks !
41
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

42
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

43
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
44
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

45
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

46
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

47
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

48
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

49
Review of Evidence - Meniscus
(Jackson JL, et al.)
  • Joint Line Tenderness Sens 76 Spec 29
  • McMurray Test Sens 52 Spec 97

50
Review of Evidence - General
(Ebell MH.)
51
Sample Management Algorithm
Write a Comment
User Comments (0)
About PowerShow.com