Exam of the Knee and Ankle I HAVE NO FINANCIAL DISCLOSURES RELEVANT TO THIS PRESENTATION
Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and or providers of commercial services discussed in this CME activity. I do not intend to discuss unapproved/investigative use of a commercial product/device in my presentation.
Case 1 Anterior Knee Pain / Knee Exam 15 y.o. female complains of 5 month history of pain in both knees. This began during school soccer season and continued through winter training and persists into the spring club soccer season. Pain is generalized through the anterior of the knee. It is exacerbated by playing sports and climbing stairs. She is taking Motrin 200 mg occasionally without much relief. She does not recall any injury that triggered the pain
Plain X-rays of the knee AP and lateral view of knee Notch view of knee Discuss how images are acquired. Discuss appearance of growth plates
Imaging of the Knee
Knee exam Inspection Inspect Knee Review Inspection and palpation of knee Identify surface landmarks on the knee Discuss how landmarks change in extension and flexion Is there redness, warmth, bruising? depending on clinical situation Discuss how to assess a knee effusion Discuss how knee effusion may influence decision making for work-up and treatment
Knee Exam - Motion Demonstrate passive and active ROM of the knee Discuss normal motion arc Discuss hypermobility at the knee Motion is primarily flexion and extension Active ROM 0-130 flex/ext Knee should have limited motion in coronal plane (varus/valgus) Patella Mobility Patella should glide freely, rising as knee extends and falling as knee flexes. Review role of patella as a force magnifier in knee flexion extension Briefly discuss patellofemoral pain biomechanics
Palpation of the Knee Demonstrate these knee exam skills Gentle compression Femoral condyles discuss knee contusions and the slow recovery process Tibial plateau role in inspecting for fracture Quadriceps tendon - Patella Tendon Dicscuss where Osgood Schlatters pain occurs and how it can be distinguished from patella tendinitis or SLJ Origin and insertion of medial collateral and lateral collateral ligament Joint Line Palpation create a distinction between the joint line and the femoral condyle
Manipulation of Knee Elicitible symptoms and instabilities Demonstrate patella grind test Discuss patella excursion and apprehension-excessive mobility of patella if it glides medial or lateral greater than one patella diameter Ligament Stress exams Demonstrate Varus and Valgus stress assess injuries to collateral ligaments Discuss and demonstrate Lachman exam assess competency of ACL Demonstrate Anterior/Posterior Drawer exam assess competency of ACL and PCL
Review Case history and make a diagnosis
Teaching Points Knee exam Discuss when MRI is appropriate Discuss how many knee problems respond to physical therapy and why Demonstrate palpation of Quad Tendon/Patella tendon/patella excursion Femoral condyles and collateral origins Course of MCL, LCL Joint line palpation Demonstrate Collateral ligament stress exam Demonstrate Lachman exam Demonstrate anterior and posterior drawer exam
Case 2 12 year old male presents with a limp and pain over the medial side of the right knee. He reports no injury. Pain has been present for 4 weeks. Faculty demonstrate a mildly antalgic gait Discuss antalgia How does antalgic hip and antalgic knee differ. Antalgic Knee pain, patients may have hamstring spasm, walk on toe. They are trying to stable knee Antalgic hip lean over affected side, knee swings freely Knee exam is normal no tenderness over medial femoral condyle
Discuss the concept of referred pain. Knee pain usually hurts where the problem is. If they are tender over the medial femoral condyle then that is where the problem is. If they have medial knee pain but no tenderness, then must consider referred pain from knee
Case 3 Leg Alignment An 18 month old toddler comes in for their first visit with you since moving to the area. He has been walking since 13 months of age. His parents express concern about the appearance of his legs and his gait. Your exam reveals a healthy toddler who has achieved appropriate developmental milestones.
When this child walks the feet point inwards about 10 degrees with some variation from stride to stride
Global assessment of legs Leg alignment Expose legs, place feet together with feet, patellae facing forward Do knees touch? Do ankles touch Standing on one leg can often bring out the deformity Gait Fluid, symmetric gait pattern Does patient Lift ankles?