HISTORY *** MECHANISM OF INJURY.. MOST IMPORTANT *** Age of patient Sport / Occupation - Certain conditions are more prevalent in particular age groups (Osgood Schlaters in youth / Degenerative Joint Disease in elderly) - Useful in determining mechanism of injury / overuse Level of Sport / Activity - Training Schedule - Position Played - Terrain - Footwear - Warm-up / Cool-down Acute Injuries - Important questions to ask: - Did the patient hear a pop or a crack? (may indicate tear of Anterior Cruciate Ligament (ACL) or meniscus) - Was there immediate swelling? (may indicate significant internal pathology) - Has the knee locked or given way since the acute injury? (locking may indicate a loose body, like a bone chip or piece of meniscus. Giving way may indicate a ligament tear or pain inhibition). Pain Characteristics Site Duration - Anterior (possible patellofemoral or referred from the hip) - Constant vs. with certain activities only Associated Symptoms - Swelling / locking / giving way Treatment to Date - For similar / related injury Past Hx of similar conditions Family Hx of related conditions Copyright 2006 Page 1 of 7 mskeducation.com
PHYSICAL EXAMINATION Observation and Surface Anatomy Anterior view Posture Musculature - Quadricep wasting Deformity - Swelling, ecchymosis, abrasions, scars Alignment - Genu varum / valgum / recurvatum / pes planus / cavus / patellar position / Q angle Appliances Gait - Excessive pronation / supination Surface Anatomy - Tibial Tubercle / Gerdys tubercle / joint line / lateral femoral condyle / Fibular head / Pes Anserine insertion / patellar retinaculum Posterior view Posture Musculature Deformity Alignment Gait - Gastrocnemius / hamstring wasting - Bakers cyst / ecchymosis / abrasions / scars - Uneven popliteal creases / gluteal folds / rearfoot varus / valgus - Trendelenburg / antalgic Lateral View Posture Musculature Deformity Alignment - Wasting - Lack of full extension / swelling / ecchymosis / abrasions / scars - Genu recurvatum, patellar position Copyright 2006 Page 2 of 7 mskeducation.com
Range of Motion (ROM) Quick tests - Squat and duck-walk (good for eliciting meniscal symptoms) - Standing - lack of full extension (possible meniscal injury or hamstring guarding) Active / Passive ROM - PM (Prime Movers), AM (Accessory Movers) Flexion - 135 - PM: hamstrings (Semimembranosus / semitendinosus / biceps femoris) - AM: Sartorius / gastrocnemius / gracilis / popliteus Extension - 15 - PM: quadriceps (Vastus lateralis / medialis / intermedius / rectus femoris) Gait Assessment - watch your patient walk and monitor for excess pronation or supination Muscle Testing Flexion Extension Medial rotation Lateral rotation - Hamstrings - Quadriceps - Semimembranosus / semitendinosus / popliteus - Biceps femoris Copyright 2006 Page 3 of 7 mskeducation.com
Patellofemoral Tests Effusion Patellar Tap - Simultaneous compression of skin from superior / inferior aspects of the joint, followed by tapping on the top of the patella with index finger - Compare with opposite knee for feeling of fluid under patella Patellar Ballottment - Smooth hand along medial aspect of the joint in a caudal direction, then compress lateral aspect of the joint to see if fluid appears on the medial side Patellar Tracking - Can be done in a sitting position with hand over patellar facets - As patient slowly extends leg, or with the patient supine and actively contracting their quadriceps Osmond Clarke Test - For patellofemoral tenderness - patient is supine and actively contracting quadriceps while examiner compresses patellofemoral tendon at the superior aspect of the patella to elicit pain Patellar Apprehension Test - For patellar subluxation / dislocation - Patient is supine. The examiner flexes knee to 20 and applies lateral pressure to the medial aspect of the patella (and vice versa) to elicit a sense of apprehension. Patellar Palpation - Retinacular tenderness / crepitous / mobility / tilt of patella Copyright 2006 Page 4 of 7 mskeducation.com
Medial & Lateral Ligament Tests (MCL / LCL) Medial Collateral Ligament (MCL) Valgus stress - Patient supine, knee flexed to 30 while examiner applies valgus stress to the knee to elicit pain / instability - Test is repeated with leg in full extension * Lateral Collateral Ligament (LCL) Varus stress - Patient supine, knee flexed to 30 while examiner applies varus stress to the knee to elicit pain / instability - Test is repeated with leg in full extension * (* instability at full extension may indicate more severe injury) Anterior Cruciate Ligament Test (ACL / PCL) Anterior Drawer Test - Patient supine, hip flexed to 45, knee flexed to 90, foot blocked & hamstrings relaxed - Examiner has hands on upper calf, thumbs on either side of tibial tubercle while slowly pulling the tibial / fibular complex forward - compare movement with the uninjured knee Lachman Test Pivot Shift Test - Patient supine, knee flexed to 20, hamstrings relaxed, distal femur stabilized with one hand, while grasping proximal tibia with other hand and slowly displacing forward - This test is more sensitive vs. the Anterior Drawer Test - Patient supine, leg supported and fully extended, foot stabilized between arm and side of the body, proximal tibia held with both hands - Examiner applies valgus and internal rotation forces, while flexing the knee - Tibia will drop back into place at approximately 30 flexion - Compare excess movement with the uninjured knee Copyright 2006 Page 5 of 7 mskeducation.com
Posterior Cruciate Tests Sag Sign - Patient is supine. Examiner flexes both hips and knees to 90. - Examiner holds the lower legs up in the air to observe for posterior displacement of the tibia Posterior Drawer Test - Same position as Anterior Drawer Test - Examiner pushes tibia posteriorally to elicit excess displacement Meniscal Tests McMurray Test - Patient supine while examiner flexes knee and hip to a tolerable position for the patient - Examiner then places one hand over joint lines while grasping the patient s heel with the other hand and applying internal / external rotational force to the lower leg to elicit pain / clunking sensation Joint Line Palpation - Patient supine with knee flexed to 90. Examiner palpates joint line from patellar tendon to posterior aspect of the joint - The joint line is easier to palpate when patient s foot is rotated internally / externally (* A locked knee or lack of full extension may be indicative of a meniscal injury *) Copyright 2006 Page 6 of 7 mskeducation.com
Other Tests Ober s Test Hamstring Stretch - For assessment of Iliotibial Band function - Patient lying on side, hips flexed to 90 - Examiner stabilizes hip with one hand, grasps upper knee with the other hand to fully flex then fully extend hip - Note is made of the resting position of the leg after this maneuver is complete in order to assess tightness of the band - Examiner then places his / her thumb over lateral femoral condyle while patient slowly flexes / extends knee - A positive test will demonstrate tightness in the band, +/- pain under examiners thumb - Palpation of the insertional sight on Gerdys Tubercle may also elicit pain - Useful for alleviation / prevention of anterior knee pain - Patient stands with feet 12-18 apart facing a low step - With hands on their waist, the patient places one heel on the step, ensuring both legs are kept straight - Maintaining a very straight back posture, the patient then forward flexes from the waist level until a stretch is felt in the hamstring area - The stretch is held for 10 seconds on each leg as a warm-up. - 3 sets of incremental stretching is recommended as a cool-down (e.g. 10 / 20 / 30 seconds). Copyright 2006 Page 7 of 7 mskeducation.com