Presentation on theme: "The Knee: Clinical Evaluation Nick Iannuzzi, MD November 28 th - 2011."— Presentation transcript:
The Knee: Clinical Evaluation Nick Iannuzzi, MD November 28 th - 2011
Outline Anatomy History Differential Diagnoses – Structured Evaluation Practice Physical Exam 2
The Knee 3
Exam Maneuvers Anterior drawer test Lachman test Pivot shift test Posterior sag sign Posterior drawer test Quadriceps active test Valgus stress test Varus stress test Patellofemoral grind test Apprehension test Joint line tenderness McMurray Test Apley grind test Bounce home test 5 WHAT? WHY? WHEN?
History Timing? Mechanism? Pain description? Swelling? Mechanical Symptoms? Instability? Baker et al 1983; Hughston et al 1985, Laprade et al 1997
Rule #1 Always compare to the other Knee!! INTERNAL CONTROL
EXAM-Getting Started Inspection/Palpation -Effusion? -Tender? -Skin Breaks? Alignment -Varus/Valgus? -Dislocated? Range of Motion (0-130+) -Mechanical Block -Contractures -Crepitus “Seek Out Disease, Don’t Hope For Health”-anonymous WHAT DO YOU SEE??
EXAM-Overview Inspection/Palpation Alignment Range of Motion (0-130+) Tracking Extensor Mechanism Stability -Provocative Tests GAIT Analysis
ACL – Anterior Drawer 15 Knee at 90 degrees Anteriorly translate the tibia with thumbs palpating relationship between femoral condyles and tibia Sensitivity 22-41% (acute injuries); 50-95% (chronic injuries)
Meniscus – Joint Line Tenderness Can palpate medial and lateral joint lines of tibia at ~90 degrees flexion Medial meniscus more prominent with IR Lateral meniscus more prominent with ER Sens 55-85%, Spec 30- 67% 23
Meniscus – McMurray’s Hyperflex knee –Hold heel in one hand –Hold knee with other –Internally rotate knee while extending to 90 degrees –Externally rotate knee while extending to 90 degrees –Can apply varus/valgus stress Sens 16-58%, Spec 77-98% 24
Patellofemoral Instability – Q angle Angle formed by –Line drawn from ASIS to center of patella –Line drawn from center of patella to tibial tubercle –Normal is 10-15 deg 25
Patellofemoral Instability – Apprehension Sign Leg hanging off table, supported by thigh Knee flexed 30 degrees Attempt lateral translation of patella Positive sign results when patient flexes quad to resist translation Sens 39% 26