The Knee Exam. History 3/6/2017. Orthopaedics. William Hey 1795 Steve E. Jordan M.D. Internal Derangement of the Knee. Augustus Thorndike, M.D.

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1 3/6/2017 The Knee Exam History William Hey 1795 Steve E. Jordan M.D. Internal Derangement of the Knee Andrews Institute Gulf Breeze, FL Orthopaedics 1889 Turn of the Century Polio Scoliosis Tuberculosis Hip Disease Foot Problems Crippled Children Now, however, a change has come over the scene; life is lived at higher pressure, and competition is greater than it used to be; anything that clogs the wheels of life entails on the sufferer loss of health, of time, and of money, incapacitates him from some occupations, and debars him from some pleasures and invigorating sports. Casting Bracing Incision Amputation Augustus Thorndike, M.D. Harvard Team Physician Such then is a routine examination that will enable one to arrive at a diagnosis at all of the important knee injuries

2 Don O Donoghue, M.D. Treatment of Injuries to Athletes 1962 The Book that Launched Sports Medicine as a Specialty The examinationof the patient may, of course, often solve the difficulty. Careful, tender but meticulous complete examination of every sprain of the knee The decision to operate or not depends on the results of a careful examination Don O Donoghue, M.D. The Knee Exam Organizing the Exam History Character Location Duration Aggravation Relief Activity Inspection Palpation Tests Unique Inspection Palpation Anterior Knee Meniscal Exam Ligamentous Exam Inspection Palpation Not Just Knees Hips Musculature Lower Leg Rotation Foot and Ankle Alignment Effusion Tenderness Peri-Patella Plica Joint Line Medial Lateral MCL LCL origin/insertion Patellar Tendon Tibial Tuberosity ASK Where? 2

3 Patello- Femoral Joint Goldthwait 1904 Boston Med J Q angle Patella Alta Trochlear dysplasia Medial Laxity Fairbank 1936 Proc Royal Soc Apprehension Sign Hughston 1968 JBJS Subluxation of the Patella Dr. Hughston Subluxation of the Patella JBJS 1968 Grating Lateral Posture VMO Dystrophy Passive Subluxation Medial Tenderness Insall 1976 JBJS Chondromalacia Patellae Patello- Femoral Joint Observation Position - Baja Alta Quadriceps Q Angle Patellar Tracking Tracking in Flexion and Extension J tracking Patello- Femoral Tests Apprehension Test (Fairbank s Test) Tilt Test Glide Test Grind Test (Clarke s Sign) Knee Flexed 30 Lateral Stress Pos. Test Apprehension 3

4 OOPs! Dorsal - Fin Patella P-F Instability Moving Patellar Apprehension Test 2 Parts Flexion with Lateral Stress Flexion with Medial Stress Pos. Test = Apprehension Lateral Only SN 100% NPV 100% Accuracy 94% Ahmad 2009 AJSM Meniscal Exam Meniscal Tests Tenderness or Clicks Joint Line Palpation Bragard Test Steinmann 2 nd Test McMurray s Test Blocked Extension Bounce Test Knee Jerk Test (Oni) McGinty Test Pain with Rotation Apley s Grind Test Bohler Test Helfet Test Payr s Test Steinmann 1 st Test Merke s Test Ege s Test Thessaly Test Anderson s Grind Test Allingham 1889 McMurray s Test Palpation Joint Line Tenderness Essential Part of Exam T.P. McMurray The Semilunar Cartilages Br Journal of Surgery 1942 SN: 30-90% SP: 30-95% Accuracy 81% 90% LR+ better for Lateral This method of evaluation is of little value if the lesion is anterior to midline Positive Test: Painful Click or Snap 4

5 Medial Lateral or Anderson s Grind Test Bounce Test Bounce Home Test Anderson & Lipscomb AJSM 1986 Apply Varus and Valgus Flexion and Extension Pos = grinding sensation SN SP : 70% False positives Infrequent Allingham Internal Derangements of the Knee Joint London 1889 SN: 35-50% SP: 65-85% LR Apleys Test Apley A.G. JBJS 1947 The Diagnosis of Meniscus Injuries- New Methods Prone Compression + Rotation Pain = Meniscus Tear Distraction + Rotation Pain = Ligament Sprain Thessaly Test aka Disco Test A New Clinical Test for Early Clinical Detection of Meniscal Teas Karachalios, et al JBJS Flexion Accuracy 94% 96% Evidence Meniscal Tests Solomon - JAMA Meniscus LR+ <3 Combination is recommended Rob -J FamPrac2001 Meta Analysis McMurray s highest PPV Malanga -Arch Phys Med Rehab 2003 McMurray s high SP JLT high SN Lowery -Arthroscopy Composite Score 5 tests- (includes history) PPV 92% Bartz CORR 2007 Review no constant and pathognomonic sign exists Konan -Knee SurgSport Arth JLT best plus Thessaly / McMurray s Better -95% Evidence Summary Meniscal Tests Exam plus History improves Accuracy Experience with the tests improved accuracy All tests trended less accurate with concomitant ligamentous injuries Tests were more accurate in young pts and acute injuries, less so with degenerative knees Combinations including JLT were best 5

6 History George Noulis 1875 Paris Sprains of the Knee Abdxn Rocking Hey Groves 1917 London On passive manipulation.. the diagnosis is a matter of considerable certainty Sir Robt Jones 1923 London The diagnosis therefore of a ruptured crucial ligament should not be very difficult A. Thorndike 1938 Harvard marked increase in the ant-post mobility suggests injury to the crucial ligaments Ligamentous Exam MCL MCL Medial Collateral Ligament Pt. Supine Apply Valgus Stress 30 degrees 0 degrees Grades I-III LCL Lateral Collateral Ligament Pt. Supine Apply Varus Stress 30 degrees 0 degrees Rotatory Instabilities ALRI Ant Drawer Pivot Shift MacIntosh Jerk Test Hughston Losee Test Side Lying Test Slocum Flexion Rot Drawer Noyes PLRI Dial Test PL Ext Rot Test Ext Rot Recurvatum Postero Lateral Drawer Reverse Pivot Shift Test Grades I-III AMRI Slocum Test PMRI Larson Anterior Drawer Test Lachman s Test Knee Flexed 90 Tibia in Neutral Endpoint Firm Soft -Absent Accuracy in Acute Injuries Poor Clinical Diagnosis of ACL Instability in the Athlete Torg, et al, AJSM 1976 Accuracy 95% 6

7 Lachman s Test Pivot Shift Test Patient Supine Relaxed Flexion - 30 Degrees Tibia Neutral R/O Posterior Subluxation Grading: I -II III Firm Soft -Absent Galway, MacIntosh 1980 Clin Ortho Sign and Symptom Is Anterior Laxity Clinically Significant? Extension IntRot. Valgus Slow Flexion ACL Lelli Test Bigger Patients Smaller Examiner PCL Posterior Instability PCL Primary Posterior Restraint Twice as strong as ACL AL Bundle 80% PLC injuries seen in 60% of PCL injuries Posterior Drawer Posterior Sag Test Quadriceps Active Test History PCL Post SAG Test First written PE sign Posterior Sag Sign Thorndike 1938 Static Test Thorndike 80% Sensitive 100% Specific Supine Knees at 90 Feet flat on Table Relax Quadriceps Observe from Side 7

8 PCL Posterior Drawer Most Sensitive Test for Isolated PCL PCL Quadriceps Active Daniel JBJS 1988 Accuracy is 60% + 90% Sensitive 99% Specific Tibial plateau 1 cm Anterior to MFC Endpoint Not as reliable as Translation Supine - Knee at 90 Feet flat on table Ask to slide foot forward > 2mm anterior motion = Pos Test Posterolateral Corner Dial Test Pt Supine Knees Flexed Dial feet externally > 15 difference = positive test Complete Exam P F J - History - Inspection - Palpation - ROM Position- Tracking- Palpation Tilt - Glide - Apprehension Meniscal- JLT -McMurray -Grind -Bounce MCL /LCL - Stress 30 degand 0 ACL /PCL - Drawer -SAG -Lachman Pivot Shift Dial Quadriceps Active Test (PCL) Thank You! Leandra Price ATC Jimmy Sims Video Ashley Ramsey ATC 8