Evaluation of Knee Problems

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Evaluation of Knee Problems

• Kevin deWeber, MD, FAAFP
• Primary Care Sports Medicine

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OBJECTIVES

• Review knee anatomy
• Explain tests to look for pathology
• Briefly introduce knee problems

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• Only by a thorough knowledge of anatomy and
  functional testing can one make an accurate
  diagnosis and direct effective care to an injured
  knee.

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Ligamentous Anatomy

• Hinged Joint
• ACL Ant Stability
• PCL Post Stability
• Lat/Med Stability LCL/MCL
• Menisci Medial/Lateral

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EXTENSOR MECHANISM The Quadriceps

• ORIGINS
• Rectus Femoris AIIS
• Vastus Group Linea Aspera
• INSERTIONS
• Patella
• Patellar Retinaculum

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Always have the patient perform a straight leg
raise to rule out an extensor mechanism rupture
after acute trauma
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FLEXOR MECHANISM
The Hamstring

• COMMON ORIGIN
• Ischial Tuberosity
• INSERTIONS
• Biceps Fibular Head
• Semimembranosus Medial Tibial Condyle
• Semitendinosus Pes Anserinus

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History

• Chief Complaint
• Antecedent event/Repetitive activity
• Previous injuries to affected area
• Attempted therapies
• Review of symptoms/Past medical history
• Occupation/Treatment Goals

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Inspection

• Lower extremity alignment
• Foot structure
• Effusion/Erythmea
• Q Angle
• Thigh atrophy

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Foot Structure Variants
Pes Planus
Pes Cavus
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Ballotment Test for Effusion
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Causes of Traumatic Effusion

• 1. ACL tear
• 2. Meniscal tear
• 3. Patellar dislocation
• 4. Fracture
• 5. Others (PCL, MCL, LCL)

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Quadriceps Angle (Q Angle)
The Angle between 1) ASIS to center of
Patella and 2) Patella to Tibial Tubercle
Men lt10 Women lt15
NORMAL
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Thigh Atrophy

• Possible sign of intra-articular pathology
• Measure either hand breadth above patella or 10cm
  above patella
• Measure 2 times
• gt 1 cm different is abnormal

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Leg Length

• FUNCTIONAL METHOD Compare heights of ASIS
  PSIS
• Add foot shims in small adjustments until level
• ANATOMICAL METHOD Measure from ASIS to Medial
  Malleous
• gt 1 cm difference is significant
• Pelvic Obliquity will confuse issue
• RADIOLOGIC METHOD Scanogram (X-ray)
• most definitive but usually not needed

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Range Of Motion
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Palpation of key structures

• Medial
• MCL
• Pes anserinus
• Medial meniscus
• Plica (ant-med)

• Lateral
• LCL
• ITB/lateral femoral condyle
• Lateral meniscus
• Fibular head

• Anterior
• Patellar tendon
• Patella
• Tibial tubercle
• Fat pad

• Posterior
• Popliteus
• Bakers cyst

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Osgood-Schlatters DiseaseClinical Description

• The most common overuse injury seen in young
  athletes
• Traction apophyseal injury
• seen in running/jumping athletes during periods
  of rapid growth

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Osgood-Schlatters DiseaseClinical Features

• History
• young athlete complains of painful enlargement of
  the tibial tuberosity
• pain worse with activity, esp. run/jump
• Exam
• tender tibial tuberosity
• tight quads /- hamstrings
• Imaging usually not necessary

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Osgood-Schlatters DiseaseImaging

• Use in severe or persistent cases to rule out
  other problems
• Not used to make the diagnosis in most cases
• May show fragmentation of the anterior tibial
  tuberosity

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Osgood-Schlatters DiseaseDifferential Diagnosis

• Sinding-Larsen-Johansson Disease
• Tibial neoplasm e.g. osteochondroma
• Patellofemoral pain syndrome
• Patellar tendonosis
• Tibial tuberosity avulsion fracture

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Osgood-Schlatters Disease Treatment

• Relative rest cross-training
• Ice
• Hamstring stretching
• Strapping of patellar tendon
• Rare temporary immobilization
• Return to play
• Pain-free with sports activity

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Osgood Schlatters Disease Surgery Indications

• Persistent, painful os after growth complete

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Sinding-Larsen-Johanssen Disease

• Apophysitis of distal patella
• Pain with kneeling and squatting.
• Tender at distal patellar pole
• Calcification is sometimes present at site of
  tenderness.
• Natural history resolution in 6 to 10 months.
• Tx ice, relative rest, ham/quad stretching

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Patellar Grind Test

• Detects pain from patellar pressure against femur
• Compress patella against femoral groove
• Gentle way pressure with fingers
• Most sensitive way press down above patella
  have patient contract quads
• POSITIVE
• Pain
• Crepitus

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Management of Patello-Femoral Syndrome

• Cross-training avoid painful activity
• VMO strength exs
• Flexibility exs (quad, hams, ITB, Achilles)
• Retinaculum stretching
• Patellar sleeve w/ cutout
• Correct hyper-pronation
• Referral
• refractory cases w/ high Q angle, tight
  retinaculum, severe crepitus

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Lateral

• Patellar Glide
• nl is 25-50 of width.
• POSITIVE TESTS
• Inflexibility
• Subluxation
• ( Apprehension)

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Management of Patellar Dislocation

• X-rays to r/o shearing fracture
• AP, lat, sunrise
• Knee immobilizer/cast in ext 3 weeks
• ROM/strength exs as pain allows
• Refer for
• Locking
• Fracture
• Recurrent dislocations

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Medio-Patellar Plica
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Management of Medio-Patellar Plica Syndrome

• Cross-training/relative rest
• NSAID 1-2 weeks
• Phonopheresis
• Injection w/ anesthetic/steroid
• Referral failed 6 months tx

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Management ofPatellar Tendinopathy

• Avoid NSAID overuse
• Restrict from further abuse
• Patellar strap (ChoPat)
• Progressive eccentric strength exs 3-6 mos

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Treatment of Pre-Patellar Bursitis

• Aspirate fluid (culture, cell count)
• Compressive dressing
• Treat suspected septic bursitis with oral
  antibiotics
• Dicloxacillin or fluoroquinolone
• NSAIDs
• F/U at 4 days
• Consider intra-bursal steroid injection

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Joint Stability Testing

• MCL Valgus Load
• LCL Varus Load
• ACL Lachman, Ant drawer, Pivot Shift
• PCL Posterior Drawer, Sag sign, Quadriceps
  Active
• Postero-lateral complex Ext Rot

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MCL Stability Apply Valgus or Medial Stress Test
in 30 flexion
LCL Stability Apply Varus or Lateral Stress
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Grading collateral ligament injuries

• Grade I mild no laxity
• Grade II partial tear laxity w/ firm end-point
• Grade III complete tear laxity w/o firm
  endpoint
• Why does it matter? Prognosis

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Treatment of MCL/LCL injuries

• PRICEMM
• Grades I-II
• knee immobilizer until pain gone
• ROM/strength exs as pain allows
• Grade III
• r/o associated injuries
• knee immobilizer at 30 NWB 3 weeks
• knee immob 30-80 NWB 4 wks
• progressive ROM/strength exs

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ACL anatomy
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Tests of ACL At 90 Flexion At 20-30
Flexion (more sensitive)
is increased translation or soft end point
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Lachman test
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Pivot Shift ACL Injury
1. Knee extended 2. Internally rotate tibia 3.
Apply valgus load
4. Flex Knee 5. At 20-30, if you feel a jerk at
Ant/Lat proximal tibia, test
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Management of ACL tears

• PRICEMM
• ROM/strength exs as pain allows
• MRI
• Referral to Orthopedics
• Surgery once edema gone
• Graft options
• Bone-patella-bone autograft
• Hamstring autograft
• Cadaver allograft

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PCL Tear
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PCL TESTS Posterior Sag
Quad Active Test
Posterior Drawer
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Management of PCL tears

• PRICEMM
• Immobilize refer to Ortho
• If no associated injuries
• ROM /strength exs as pain allows
• If associated with other injuries
• Surgical repair
• MCL
• Postero-lateral corner

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Injury to Postero-Lateral Corner
External Rotation Test
Flex knees to 30. Externally rotate
tibia. Injured limb will have
external rotation. Repeat at 90 flexion
(persistent incr ER is from combined PLC/PCL
injury)
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Popliteus Tendonitis

• Function resists posterior translation of tibia
• Pain postero-lateral
• Garrick Test pain with resisted ext rotation of
  leg
• Seen w/ downhill running
• Treatment
• Modify running
• NSAID/ice
• Hamstring stretching
• Eccentric quad strength
• Refer for injection if not responding

Popliteus
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Flexibility testing

• Inflexibility is a common culprit in overuse
• Hamstring
• Quadriceps
• Ilio-tibial band (ITB)
• Gastro-soleus complex
• Patellar glide and tilt

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Quadriceps flexibility
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Hamstring flexibilityPopliteal AngleGoal 0
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Gastro-soleus flexibility
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• ITB flexibility
• Ober test
• Tight ITB will remain ABducted
• Pain ITB injury

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Ilio-Tibial Band Friction Syndrome
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Management of ITB Friction Syndrome

• Reduce run mileage/hills/banked surfaces
• NSAID/ice massage/phonopheresis
• ITB stretching
• Correct overpronation
• Gradual return-to-running program
• Referral for injection if fail above

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Miscellaneous Tests

• McMurray Meniscal injury
• Apley Test Meniscal vs ligament injury
• Bounce Home Test meniscal injury, effusion
• Patellar grind test PFS, chondromalacia

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Normal Meniscus
Meniscal Tear
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McMurray Test

• MEDIAL MENISCUS
• Flex knee maximally
• Externally rotate tibia
• Varus stress
• Extend Knee

• LATERAL MENISCUS
• Flex knee
• Internally rotate tibia
• Valgus stress
• Extend knee

is painful pop over Medial or Lateral Joint Line
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McMurray Test
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Apley test
Compression for Meniscal Injury
Distraction for Ligamentous Injury
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Full Flexion TestPain at full flexion suggestive
of posterior horn tear
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Bounce Home Test
1. Flexion
Normal
2. Passive Extension
Abnormal is lack of full extension (meniscal
tear, loose body, effusion)
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The accuracy of physical diagnostic tests for
assessing meniscal lesionsof the knee A
meta-analysis.Bijl D et al. JFP Nov 200150(11)

• The diagnostic accuracy of meniscal tests is poor
• These tests are of little value for clinical
  practice.
• McMurray test and joint line tenderness
  indicatedlittle discriminative power for these
  tests.
• Only the predictive value of a positive McMurray
  test was favorable.

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Management of Meniscal Tears

• Weight-bearing as tolerated
• ROM/strength exs as pain allows
• MRI to confirm if recovery not prompt
• Indications for referral
• Elite athletes
• Symptomatic after 3 months
• Locking
• Unable to fully extend knee

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Who needs knee xrays after trauma?Ottawa Knee
Rules

• Any of the following
• Age lt 1 or gt55
• Tenderness over patella
• Tenderness over fibular head
• Inability to walk 4 steps immediately and when
  examined
• Unable to flex knee 90d
• 100 sensitivity and neg predictive value

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Osteochondritis Dissecans Clinical Features

• History
• Vague activity-related knee pain
• /- clicking, locking, giving way
• Physical Exam
• Decreased or painful motion
• May be effusion
• Poorly localized joint line tenderness

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Wilson Test
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 8
- AUGUST 98
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• Imaging
• Tunnel View reveals radiolucent area
• Bone scan if x-rays negative
• MRI best for staging, prognosis

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Osteochondritis DissecansTreatment

• Orthopedic Consultation
• Stage 1 Conservative
• Activity restriction or immobilization 6-8 wks
• Surgery if fails to heal
• Stage 2 Controversial
• Stages 3 4 Operative

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THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 8
- AUGUST 98
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Review

• Only by a thorough knowledge of anatomy and
  functional testing can one make an accurate
  diagnosis and direct effective care to an injured
  knee.

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QUESTIONS?