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History and examinationof the knee Mark Blyth Consultant Orthopaedic Surgeon Glasgow Royal Infirmary
PAIN SWELLING GIVING WAY Patellofemoral Poorly localised AnteriorAntero-medial Antero-lateral Posterior Bilateral Worse stairs, hills, sitting, start up, squatting Medial/lateral joint line Well localised Single finger Referred pain From hip From spine SWELLING Effusion Suprapatellar swelling Both hands Not effusion Infrapatellar swelling Single finger Fragmentary Hard lump Localised to joint line Extra-articular Location Bursae, meniscal cysts etc GIVING WAY Unstable ligament Knee gives out Pivoting sensation Signif after effect – swelling and disability No pattern Difficulties with uneven ground PFJ/ pain quads inhibition Preceding ant knee pain Frequent No after effects Ass PFJ activities Hyperextension sensation Ass patellar click Patellar instability History of patellar dislocation Patellar clunk Swelling possible
LOCKING HISTORY OF INJURY True meniscal locking Block to extensionMed/lat localised pain Unlock several minutes +/- swelling Ass squatting Rotation to relieve Pseudolocking PFJ Occurs at 300 Transient Frequent No swelling Loose body Not activity specific Not transient Knee immobile several minutes Poss palpable fragment HISTORY OF INJURY Cruciate injury Heard/felt pop Immed swelling Contact/ non-contact sport Stopped playing Complex ligament injury High energy mechanism Contact sport Swelling disproportionate to pain Meniscal injury History of squatting Twisting injury Delayed swelling PFJ injury Direct blow patella Immed swelling
NEUROVASCULAR EXAMINATIONLOOK FEEL MOVE TEST STAND Walk Ant/post Alignment Scars/sinuses Wasting Swelling/effusion Squatting Kneeling SIT Patellar tracking on extension Lag on extension Crepitus on extension Pain on resisted extension SUPINE EXTN Flexion contracture Scars/sinuses Wasting Swelling/effusion Quads mechanism tenderness Confirm passive ROM Foot lift test Patellar stress test Patellar restraint test SUPINE Joint line tenderness Postmed and lat tendernesss Ant/post drawer Lachmans MCL/LCL laxity PLC laxity Pivot shift HIP EXAMINATION NEUROVASCULAR EXAMINATION
Ligament evaluation Difficult in the acute phase/ anxious patient+/- EUA Lachman (Jonsson 1982, Torg 1976) Beware PCL false positive Pivot shift may be negative ACL
PCL Posterior drawer test at 900 Grade mm (tibial condyles anterior) Grade mm (condyles in line) Grade mm (tibial condyles posterior) Grade 3 suspect collateral injury
MCL/posteromedial cornerValgus stress at 300 Grade 1 0-5mm Grade mm Grade 3 10+mm Grade 3+ Valgus in extn Grade 3+ suspect posteromedial corner and cruciate injury
LCL/posterolateral cornerVarus stress at 300 Grade 1 0-2mm Grade mm Grade 3 10+mm Dial test at 300 only Posterolateral corner at PCL+posterolateral corner Reverse pivot shift test Hughstons hyperextension ext rotation test Grade 2+3 suspect posterolateral injury
Clinical examination Perch point 300 Inverted J sign
Clinical examination Q angle > 20 degrees significant
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