PRINCIPLES OF EXAMNINIG THE KNEE
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1 Welcome! Pignon, Haiti IS IT. GOOD MORNING LORD! OR GOOD LORD, MORNING! PRINCIPLES OF EXAMNINIG THE KNEE Greg Bennett, PT, DSc Excel Physical Therapy Marymount University Rules Hx often diagnostic Least to most threatening Sx trump exam Develop consistent routine Don t inflame inflamed tissue If we agree on everything, one of us is unnecessary 1
2 EXAMINATION GOALS KEYS TO SUCCESS 1. ESTABLISH OR CONFIRM DIAGNOSIS 2. ESTABLISH TREATMENT 3. LIMIT PROGRESSION 4. BASELINE PATIENT STATUS HISTORY THOROUGHNESS/ ACCURACY KNOWLEDGE of ANATOMY and MECHANICS EXPERIENCE HISTORY OF INJURY ACUTE HISTORY Adequate history taking can often be diagnostic; include discovery of previous injuries. Mechanism of injury/ knee position Pop, snap or click? Swelling-onset Post-injury function CHRONIC HISTORY CURRENT SYMPTOMS History of injury Onset during what? Noisy knee? Locking/ buckling Stairs painful? ADL/sports Swelling/pain Swelling Instability Pain Dysfunction 2
3 SWELLING EFFUSION When How much? Rapid: Major trauma vascular tissue injury Gradual: PFJS, DJD, tendonitis, chronic instabilities SYMPTOM ONSET POSSIBILITIES: Sudden Onset: Trauma Sudden-trauma Gradual- no trauma Sudden-no trauma Gradual-trauma Meniscal tear Collateral ligament strain or sprain. ACL or PCL tear Fracture TF or PF Dislocation POSSIBILITIES: Sudden Onset: No Trauma Neoplasm Sub-clinical injury Overuse Final Straw POSSIBILITIES: Gradual onset: no trauma Meniscus Subluxation or dislocation PFJS, DJD, tendonitis Impingement; Plica 3
4 POSSIBILITIES: Gradual onset: trauma Grade I or II Sprain/Strain Subluxation PFJS, DJD Impingement PAIN-beware of correlations (no absolutes) Sudden: Trauma: major injury Prolonged sitting: PFJS, AKPS Stairs/squats: PFJS, tendonitis ACL deficiency Changing direction: Instability; subluxation; meniscal lesions PAIN CORRELATIONS Mechanism of Injury: Associated Mechanics Locking, popping Grating, cracking Sharp Dull Morning pain With activity Meniscus PFJS Many PFJS, instability DJD Synovitis/tendonitis ACL INJURIES Cutting, twisting Hyperextension Deceleration POSTERIOR LATERAL CORNER Lateral collateral is a pencil-like cord Popliteus tendon The capsule here is open, weak and prone to injury Together with the anterior cruciate 4
5 PCL INJURIES MCL INJURY Direct blow Hyperflexion Valgus stress Weight bearing, foot fixed CKC LCL INJURY PATELLA INJURIES Varus stress Weight bearing, foot fixed CKC Direct blow Twisting, cutting MENISCAL INJURIES Categorizing Injuries Twisting, cutting Weight bearing 5
6 FIRST DEGREE SPRAIN SECOND DEGREE SPRAIN Mild symptoms Min. tender Normal motion Re-occurs Min. tearing Mod. Symptoms Loss of function Loss of motion Unstable Becomes arthritic? Partial tear THIRD DEGREE SPRAIN INTERPERTATION Severe symptoms Loss of unction Marked loss of motion Unstable Arthritis Complete tear R/O referral Scan spine Analysis Confirmation Diagnosis Problem list (goals) Physical Examination OBSERVATION Gait/ activities Posture Deformity/ alignment Swelling Atrophy Rubor/redness Stress 6
7 PALPATION LIGAMENT TESTS Calor/temperature TTP Swelling Sensation Structure/ patella Pulses Crepitus Varus/valgus Drawer Lachman Pivot shift/rps Meniscal TEST SENSITIVITY Test Specificity Sensitivity is a statistical measure of how well a classification test correctly identifies a condition Sensitivity is one measure of how good a test is. It is the number of "true positives" plus "false negatives," divided by the percent of cases picked up by the test. Specificity: Are you testing what you think you are testing? Specificity is a statistical measure of how well a test correctly identifies the negative cases, or those cases that do not meet the condition under study. It is defined as the number of "true negatives" plus the number of "false positives" divided by the percent of negative results that are really negative. Special Tests - ACL Injury Lachman s Test Lachman Test Gold Standard 30 flexion 7
8 Lachman s Test Anterior Drawer Sensitivity Range: % Specificity Range: 100% Less sensitive 45 hip flexion 90 knee flexion Sources: Dehaven 80; Donaldson 85; Liu 95; others Anterior Drawer Sensitivity Range: 10-76% Specificity Range: 50-86% Influenced by secondary restraints PIVOT SHIFT: Functional Indicator START Extension IR Valgus ITB dependent Sources: Dehaven 80; Rubenstein 94; Torg 76; Kim 95; others PIVOT SHIFT PIVOT SHIFT FINISH Flexion IR valgus Sensitivity Range: 27-71% Specificity Range: % (Torg) Influenced by secondary restraints Sources: Galway 80; Rubenstein 94; Torg 76; Donaldson 85; others 8
9 REVERSE PIVOT SHIFT: ACL and PCL stressed START Flexion ER Valgus MCL+dependent REVERSE PIVOT SHIFT FINISH Extension ER valgus REVERSE PIVOT SHIFT Varus/Valgus stress for LCL and MCL Injury Poorly Studied (Rubenstein 94) Sensitivity: 26% Specificity: 95% (PCL) Influenced by secondary restraints Valgus Stress: MCL Varus Stress: LCL At 30 flexion, the cruciates are in their most relaxed state, and pathologic laxity palpated is capsular laxity Medial capsular layers provide stability to valgus stresses at knee & are primary stabilizer at 0-30 of flexion Role of LCL increases w/ joint flexion, as posterolateral structures become lax With joint flexion, resistance by ACL decreases, but large forces are found in PCL at 90 degrees of flexion 9
10 Valgus/Varus Stress: Repeated at 0 Degrees If still lax at 0, what does that mean? Secondary restraints also injured. What are they? Meniscii MCL/LCL Capsule Muscles? MENISCAL TESTS McMurray (1942) Thessaly test (2009) Apley Grind Point tenderness Scans Thessaly Test Supports the patient holding outstretched hands while the patient stands flatfooted. Patient then rotates their knee and body, internally and externally, three times Keep knee flexed at 20 degrees. Suspected meniscal tears will experience joint-line discomfort. Clin J Sport Med Jan;19(1):9-12 Sensitivity 90.3% Specificity 97.7% Thessaly Test Positive predictive value of 98.5% Negative predictive value of 86.0% Clin J Sport Med Jan;19(1):9-12 MENISCAL TESTS MENISCAL TESTS Sensitivity Range: 29-63% Specificity Range: 29-57% Influenced by numerous tissues Pain in the posterior aspect of the knee with maximal flexion may be indicative of a posterior horn meniscal tear. Sources: Anderson 86; Boeree 91; Fowler89; Noble 80; others 10
11 Special Tests - PCL Injury Posterior Drawer Test Sag Sign Quad-Active Test TIBIAL SAG (DROPBACK): PCL Tibial drop back test: the examiner compares the prominence of the proximal tibia to the femoral condyles with the knee flexed to 80 Also done with hips/knees at 90 TIBIAL SAG (DROPBACK): PCL Poorly Studied: Rubenstein 94 Sensitivity Range: 79% Specificity Range: 100% Anterior Knee Pain Most common knee complaint Need to discern between patellar pain instability both pain and instability Patello-Femoral Exam Passive Patellar Tilt Lower Extremity Alignment Generalized Laxity Locations of Tenderness Patellar Alignment Passive Patellar Tilt Lateral and Medial Patellar Glide Patellar Apprehension Crepitation Q angle at 90 degrees Lifting the lateral border of the patella superiorly to assess the tightness of the lateral patellar-femoral retinaculum Inability to achieve horizontal is a positive test (excessively tight lateral structures) 11
12 Patellar Glides Patellar Glide Test Lateral Patellar Glide Manually sliding the patella laterally Apprehension sign: when a lateral patellar glide produces fear of dislocation Medial Patellar Glide Manually sliding the patella medially Q Angle Defined as the angle between the axis of the femur to the center of the patella the center of the patellar to the tibial tubercle Assessment in flexion is more significant Assessed in full knee extension and at 30 and 90º of knee flexion An increased Q angle increases the likelihood of lateral patellar subluxation Patellar Instability Lateral patellar subluxation or dislocation knee flexion tibial external rotation valgus Etiologies: an increased Q angle in early flexion incompetent MPFL shallow trochlea short trochlear groove (relative alta) Radiographs Lateral Radiograph Patellar Height Blumenstaat s line Physeal scar Lateral Radiograph Insall-Salvati Ratio Defined as the length of the patella in relation to the length of the patellar tendon 12
13 PTs Management of Patellofemoral Problems PATELLOFEMORAL TESTS Differentiate between pain and instability Instability: -Provide pt with a patellar sleeve, preferably one with a lateral patellar support -Initiate therapy referral for ROM,quad strengthening and hip ER strengthening Perkins Sign (posterior palpation) Grind (2 angles) AROM crepitance Cinema sign Clarkes sign PATELLOFEMORAL ASSESMENT Stability Orientation Muscle Function Crepitation Irritation SPECIAL TESTS Girth Ballotment Bounce home Q angle Alta/ baja patella SPECIAL TESTS ACTIVE MOTION Diagnostic Imaging X-ray MRI CT Scan Deficits Quality Crepitance Apprehension Squatting?? 13
14 PASSIVE MOTION RESISTED MOTIONS Deficits End feel Painful arc Crepitance Joint play Flexibility Contractile vs. noncontractile Interpretation End Feel! EXERCISE DYNAMOMETERS Not diagnostic Usually not appropriate with acute injury GENERAL HEALTH Hypermobility Joint conditions Neurology Medications Injections/steroids GENERAL HEALTH Outcomes Measures Allergies Infections Weight Mental status?? History CA LYSHOLM KNEE RATING SCALE Tegner Scale Cincinnati Scale Etc. Adult population, orthopedics 14
15 MUSCULOSKELETAL EXAMINATION CONCLUSIONS History Active Movements Passive Movements Resisted Movements Palpation Specific Orthopedic Tests X-Ray Correlation Treatment plan Thank You! Pignon, Haiti 15
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