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Musculoskeletal Curriculum History & Physical Exam of the Injured Knee Copyright 2005.

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Presentation on theme: "Musculoskeletal Curriculum History & Physical Exam of the Injured Knee Copyright 2005."— Presentation transcript:

1 Musculoskeletal Curriculum History & Physical Exam of the Injured Knee Copyright 2005

2 2 Authors Kathleen Carr, MD Madison Residency Program Dennis Breen, MD Eau Claire Residency Program Dan Smith, DO

3 3 Contributors Marguerite Elliott, DO Jeff Patterson, DO Jerry Ryan, MD

4 4 Goal Learn a standardized, evidence-based history and physical examination of patients with knee injuries WHICH WILL : Enable family medicine resident physicians to accurately diagnose common knee problems throughout the full age spectrum of patients seen in family medicine

5 5 Competency-Based Objectives Patient care – focused history and exam Professionalism – respect, compassion Interpersonal and communication skills – differential diagnosis Medical knowledge base – anatomy, injury mechanisms Systems based practice – accuracy, time-efficiency

6 6 Assessing a knee injury Components of the assessment include Focused history Attentive physical examination Thoughtfully ordered tests/studies for future discussion

7 Focused History

8 8 Focused History Questions Onset of Pain Date of injury or when symptoms started Location of pain* Anterior Medial Lateral Posterior

9 9 Focused History Questions 2 Mechanism of Injury - helps predict injured structure Contact or noncontact injury?* If contact, what part of the knee was contacted?  Anterior blow?  Valgus force?  Varus force? Was foot of affected knee planted on the ground?** Valgus alignment = distal segment deviates lateral with respect to proximal segment. Patellas Touch

10 10 Focused History Questions 3 Injury-Associated Events* Pop heard or felt? Swelling after injury (immediate vs delayed) Catching / Locking Buckling / Instability (“giving way”)

11 11 Instability - Example ion.JPG Patellar dislocation

12 12 Focused History Questions 4 Degree of Immediate Dysfunction |     | Unable to Antalgic Continued Ambulate Gait* to Participate

13 13 Focused History Questions 5 Aggravating Factors Activities, changing positions, stairs, kneeling Relieving Factors/treatments tried Ice, medications, crutches History of previous knee injury or surgery

14 14 Historical Clues to Knee Injury Diagnoses Noncontact injury with “pop”ACL tear Contact injury with “pop”MCL or LCL tear, meniscus tear, fracture Acute swellingACL tear, PCL tear, fracture, knee dislocation, patellar dislocation Lateral blow to the kneeMCL tear Medial blow to the kneeLCL tear Knee “gave out” or “buckled”ACL tear, patellar dislocation Fall onto a flexed kneePCL tear

15 Physical Exam

16 16 Physical Exam - General Develop a standard routine* Alleviate the patient's fears GENERAL STEPS Inspection Palpation Range of motion Strength testing Special tests

17 17 Physical Exam - Exposure Adequate exposure - groin to toes bilaterally Examine in supine position Compare knees

18 18 Observe – Static Alignment Patient stands facing examiner with feet shoulder width apart Ankles, subtalar joints – pronation, supination Feet – pes planus, pes cavus ( Pes planusPes cavus (

19 19 Patient then brings medial aspects of knees and ankles in contact Knees – genu valgum (I), genu varum (II) Observe – Static Alignment ( Genu valgumGenu varum

20 20 Observe – Dynamic Alignment Pronation/Supination may be enhanced with ambulation Antalgic gait indicates significant problem (anti = against, algic = pain)

21 21 Inspect Knee Warmth Erythema Effusion* Evidence of local trauma Abrasions Contusions Lacerations Patella position Muscle atrophy

22 22 Inspect Knee-Related Muscles Quadriceps atrophy Long-standing problem Vastus medialis atrophy After surgery

23 23 Normal Knee – Anterior, Extended

24 24 Surface Anatomy - Anterior, Extended* Patella Hollow Indented

25 25 Normal Knee – Anterior, Flexed

26 26 Surface Anatomy - Anterior, Flexed Head Of Fibula Patella Tibial Tuberosity

27 27 Palpation – Anterior* Patella: Lateral and Medial Patellar Facets Superior And Inferior Patellar Facets Patellar Tendon** Lateral Fat Pad Medial Fat Pat

28 28 Surface Anatomy - Medial Medial Femoral Condyle Patella Joint Line Medial Tibial Condyle Tibial Tuberosity

29 29 Palpation - Medial Medial Collateral Ligament (MCL)* Pes anserine bursa** Medial joint line

30 30 Surface Anatomy – Lateral Patella Head Of Fibula Tibial Tuberosity Quadriceps

31 31 Palpation – Lateral* Lateral joint line Lateral Collateral Ligament (LCL)**

32 32 Palpation - Posterior Popliteal fossa* Abnormal bulges Popliteal artery aneurysm Popliteal thrombophlebitis Baker’s cyst

33 33 Range Of Motion Testing Extension Flexion 0º 135º Describe loss of degrees of extension Example: “lacks 5 degrees of extension” Locking* = patient unable to fully extend or flex knee due to a mechanical blockage in the knee (i.e., loose body, bucket-handle meniscus tear)

34 34 Strength Testing Test knee extensors (quadriceps) and knee flexors (hamstrings) Can test both with patient in seated position, knees bent over edge of table Ask patient to extend/straighten knee against your resistance Then ask patient to flex/bend knee against your resistance Compare to unaffected knee

35 35 Special Tests – Anterior Knee Pain Patellar apprehension test* ( apprehension.htm) Patellofemoral grind test** Starting position Push patella laterally

36 36 Special Tests - Ligaments Assess stability of 4 knee ligaments via applied stresses* Anterior Cruciate Posterior Cruciate Lateral Collateral Medial Collateral

37 37 Stress Testing of Ligaments Use a standard exam routine Direct, gentle pressure No sudden forces Abnormal test 1. Excessive motion = laxity What is NORMAL motion?* 2. Soft/mushy end point**

38 38 Collateral Ligament Assessment Patient and Examiner Position*

39 39 Valgus Stress Test for MCL* Note Direction Of Forces

40 40 Video of Valgus Stress Test Click on image for video

41 41 Varus Stress Test for LCL* Note direction of forces

42 42 Video of Varus Stress Test Click on image for video

43 43 Lachman Test* Patient Position Physician hand placement

44 44 Lachman Test 2 View from lateral aspect* Note direction of forces

45 45 Video of Lachman Test Click on image for video

46 46 Alternate Lachman Test Click on image for video

47 47 Anterior Drawer Test for ACL Physician Position & Movements* Patient Position Note direction of forces

48 48 Posterior Drawer Testing- PCL* Note direction of forces

49 49 Assess Meniscus – Knee Flexion Most sensitive test is full flexion* Examiner passively flexes the knee or has patient perform a full two-legged squat to test for meniscal injury Joint line tenderness** Flexion of the knee enhances palpation of the anterior half of each meniscus

50 50 Tests that we do not recommend routinely Pivot-Shift* - for ACL tear McMurray Test**- for meniscus tears

51 51 Review of Evidence – ACL* Lachman TestSens 87%Spec 93% Anterior DrawerSens 48%Spec 87% Pivot Shift TestSens 61%Spec 97% (Jackson JL, et al.)

52 52 Review of Evidence - Meniscus Joint Line TendernessSens 76%Spec 29% McMurray TestSens 52%Spec 97% ( Jackson JL, et al.)

53 53 References Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I. History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam Physician 2003;68: Ebell MH. A Tool for Evaluating Patients with Knee Injury. Family Practice Management. March 2005: Jackson JL, O’Malley PG, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med. 2003;139: Malanga GA, Andrus S, Nadler SF, McLean J. Physical Examination of the Knee: A Review of the Original Test Description and Scientific Validity of Common Orthopedic Tests. Arch Phys Med Rehabil 2003;84: Solomon DH, Simel DL, Bates DW, Katz JN. Does this patient have a torn meniscus or ligament of the knee? Value of the Physical Examination. JAMA 2001;286:

54 54 Video of Knee Exam

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