History: Pain Traumatic vs. atraumatic Acute vs Chronic Mechanism of injury Swelling, catching, instability Previous evaluation and treatment General Setup Examine standing, sitting and supine Evaluate gait Examine hip and back Patient needs to be in shorts Examine both knees Inspection: Leg length discrepancy Bruising Redness or discoloration Swelling Distal edema Scars Atrophy Shoes Palpation: Localize tenderness Palpate o Effusion An effusion indicates high probability of internal derangement within the knee o Push down on the patella (PF arthritis, chondromalacia) patella grind test o Joint line anterior and posterior (meniscus, articular cartilage) o Medial condyle (patellar dislocation, MCL, and plica) o Lateral condyle (IT band tenderness) o Pes anserine (Pes anserine bursitis) o Patellar tendon/tibial tubercle (patellar tendinitis, Osgood schlatters, sindig Larsen)
Range of motion: Compare active and passive ROM o Look for pain o Note block to full extension or flexion o Evaluate patellar tracking o Feel for catching, popping, crepitus o Relaxation by patient is key for good exam Neurological: Motor function Sensation Vascular: Pulses Skin color, capillary refill, swelling X-Rays: Essential part of knee exam o Standing AP, lateral and merchant views o If over 40; include flexed PA (Salt Lake view) Stability tests ACL Lachmans o Knee at 30 degrees flexion o One hand grabs the thigh o One hand grabs the tibia, THUMB ON THE PES o Try and translate the tibia anteriorly with your right hand o You should feel a FIRM endpoint o Not so much about how far it travels, but more about the endpoint.
Anterior drawer o Knee to 90 degrees. o Sit on the foot o Two hands behind the tibia, try and bring the tibia forward o Should NOT be able to significantly translate the tibia. Stability tests ACL (Continued) Pivot Shift o Anterior lateral subluxation of tibia and reduction at knee joint with valgus, compression and rotational force
Stability tests PCL Posterior drawer o Knee to 90 degrees o Two hands on the tiba o Try and push the tibia posteriorly o Should NOT have any significant movement. o Examine neutral rotation as well as internal/external rotation o Posterior sag Stability tests MCL Valgus stress o Knee to 20 degrees flexion This relaxes the posterior capsule which can be tight and falsely provide medial stability o Superior hand braces against the lateral knee as a post o Inferior hand grabs the ankle. o Valgus stress provided Should have a firm endpoint Should be painless Stability tests LCL Varus stress o Knee to 20 degrees flexion o Grab the posterior thigh fat with your superior hand o Grab the ankle with your inferior hand o Provide a varus stress o Should feel a firm endpoint.
Stability tests Extensor Mechanism Extensor Mechanism o SLR (straight leg raise) o Extension lag with active knee extension o Palpable defect o Patella baja or alta Other Tests Meniscal pathology o McMurrays: Knee is internally and externally rotated in flexion and brought into extension A palpable/audible/painful click is a positive test o Joint line tenderness Push on the medial and lateral joint line Patellar maltracking o Apprehension test Apply a lateral pressure to the patella and bring the knee into flexion If the patient feels uncomfortable or like the patella wants to dislocate, positive test o J Sign Tracking of patella from full extension to full flexion Positive sign when patella tracks non-linear
Typical presentations ACL tear o Sudden onset of pain with physical activity, sometimes with an audible pop and inability to bear weight or knee feels unstable. o On exam: Effusion, difficulty with ROM, inability to fully extend knee. Positive Lachmans May or may not have positive joint line tenderness o Treatment: Brace for comfort Referral to ortho for eval and reconstruction Patellar dislocation o Younger patient o Need to ask if this has happened previously o Usually state that they dislocated their knee following either a contact or noncontact twisting injury. o On exam: Possible effusion Pain on the medial patella, medial femoral epicondyle Positive apprehension test o Treatment: Patellar stabilizing brace Can be WBAT Avoid contact activities Referral to ortho for eval
Typical presentations (Continued) Meniscal injury o Male or female o Twisting injury with physical activity. o Pain with catching or locking of the knee, possible instability o On exam: Positive effusion Possible restriction to ROM Positive joint line tenderness Positive McMurrays Arthritis exacerbation o Older patient o Insidious onset, although sometimes acute o Mild to no effusion o Painless restriction to ROM common Referred pain o Hip rotation (supine) rule out hip pathology o Straight leg raise rule out lumbar pathology