THE KNEE Tim Amshoff Moore Traditional School Applied Sports Medicine

WHAT SHOULD I BE ABLE TO DO? Student will learn the evaluation process of using HOPS (History Observation Palpation Special Tests). Student will learn the evaluation process of using HOPS (History Observation Palpation Special Tests). Student will learn how to perform the orthopedic special tests for determining the nature of injury. Student will learn how to perform the orthopedic special tests for determining the nature of injury.

KNEE EVALUATION Knees are what is always seen and determined to be most serious. Knees are what is always seen and determined to be most serious. Check out the video on cteonline.org Check out the video on cteonline.org

ANATOMY OF THE KNEE

LOOK AT IT THIS WAY

MUSCULAR ANATOMY

QUAD MUSCULATURE VMO VMO VLO VLO Rectus femoris Rectus femoris

SO, WHAT KIND OF INJURIES DO WE LOOK FOR? Chronic Chronic Degeneration; results in replacement of joints Degeneration; results in replacement of joints syndromes syndromes Overuse Overuse Tendinitis Tendinitis bursitis bursitis Acute Acute Sprains/strains dislocations/fractures Sprains/strains dislocations/fractures contusions contusions

SO, LET’S TRY IT OUT On the next slide you are going to see how we check for joint stability (ligaments). Look at it close. This is what you will try on your partner and be checked for competency. On the next slide you are going to see how we check for joint stability (ligaments). Look at it close. This is what you will try on your partner and be checked for competency.

QUAD MUSCULATURE VMO- terminal extension VMO- terminal extension VLO VLO VIO VIO Rectus femoris Rectus femoris

THE KNEE HISTORY Pain Pain Contact vs noncontact Contact vs noncontact Effusions Effusions Mechanical symptoms Mechanical symptoms Locking Locking Instability (falls) Instability (falls) Initial treatment Initial treatment

THE KNEE HISTORY Continue work/play? Continue work/play? Medications Medications Occupation/Sport Occupation/Sport Time tables Time tables

PFA-HISTORY Theatre sign- pain with prolonged sitting (as in theatre or planes) Theatre sign- pain with prolonged sitting (as in theatre or planes) Pain with stairs

PHYSICAL EXAM OF THE KNEE Inspection Inspection Palpation Palpation Range of Motion Range of Motion Special tests Neurovascular assessment

INSPECTION Effusion Effusion Joint swelling Joint swelling Ecchymosis Ecchymosis discoloration discoloration Edema Edema Localized swelling Localized swelling Q angle Angular deformities Muscular asymmetry

PALPATION ANTERIOR Tibial tubercle Tibial tubercle Infrapatellar tendon Infrapatellar tendon Quad insertion Quad insertion Crepitus ? Crepitus ? MEDIAL MCL Meniscus Tibial plateau Femoral condyle

PALPATION LATERAL LATERAL Head of the fibula Head of the fibula LCL LCL Meniscus Meniscus Tibial plateau Tibial plateau Femoral condyle Femoral condyle Gerdy’s tubercle Gerdy’s tubercle POSTERIOR Menisci (posterior horns) Popliteal fossa Hamstring tendons

GRADING LIGAMENT INJURIES

ACL SPECIAL TESTS Anterior drawer Anterior drawer Lachman test Lachman test Pivot shift test Pivot shift test Valgus stress test at full extension! Valgus stress test at full extension!

REMEMBER ACL injuries happen when ACL injuries happen when no one is around (no contact) no one is around (no contact) There is sudden deceleration There is sudden deceleration Pop or snap is felt Pop or snap is felt Effusion in first 12 hours Effusion in first 12 hours Blood is aspirated form joint Blood is aspirated form joint

ACL: PHYSICAL EXAM Decreased ROM Decreased ROM Effusion-hemarthrosis, immediate Effusion-hemarthrosis, immediate + Instability tests + Instability tests Lachman: most accurate Lachman: most accurate Pivot shift Pivot shift Anterior drawer Anterior drawer + MCL and meniscus tests + MCL and meniscus tests

LIGAMENT EXAM Translation + ENDPOINTS!

+ PIVOT SHIFT Palpable clunk as the lateral tibial condyle reduces on the femur

TREATMENT Trying to figure it out? Trying to figure it out?

“PARTIAL” ACL TEAR > 40% ACL substance > 40% ACL substance + Lachman, - pivot shift + Lachman, - pivot shift Clinically Clinically Most behave functionally as full tears Most behave functionally as full tears Continued shifting ↑ ’s risk of meniscus damage Continued shifting ↑ ’s risk of meniscus damage Rx as full tear Rx as full tear

ACL TREATMENT Surgical or Nonsurgical ? modify activity ? modify activity RICE RICE Hamstrings, gastroc! Hamstrings, gastroc! Functional bracing ? Functional bracing ? 9-12 months 9-12 months

MCL INJURIES HISTORY HISTORY Mechanism = valgus stress Mechanism = valgus stress Medial joint line pain Medial joint line pain Lack of large effusion Lack of large effusion Difficulty weight-bearing Difficulty weight-bearing

MCL INJURIES Treatment Of Grade 1 &2 Treatment Of Grade 1 &2 Early mobilization Early mobilization Weight-bearing as tolerated Weight-bearing as tolerated Hinged knee brace Hinged knee brace PRICES PRICES Recovery 4-6 weeks Recovery 4-6 weeks

PCL INJURIES Mechanism Mechanism Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot MVA = dashboard injury MVA = dashboard injury Effusion (less than with ACL) Effusion (less than with ACL) Shifting/instability (chronic) Shifting/instability (chronic) Less distinctive Less distinctive

XRAYS AP AP Lateral Lateral Tangential Tangential

KNEE- LATERAL XRAYS Patella Patella Fat pads/ bursae Fat pads/ bursae Evaluate avulsion fx Evaluate avulsion fx

KNEE- TANGENTIAL XRAYS Assess patellofemoral joint Assess patellofemoral joint Patellar tilt Patellar tilt Lateralization Lateralization Depth of trochlear Depth of trochlear groove groove

LATERALIZATION AND TILT

PATELLAR INSTABILITY Acute patellar dislocation Acute patellar dislocation Acute patellar subluxation Acute patellar subluxation Patellar tracking dysfunction Patellar tracking dysfunction

PATELLAR DISLOCATION History Mechanism = pivot Mechanism = pivot Immediate effusion Immediate effusion May visualize patella dislocated laterally May visualize patella dislocated laterally + Instability (chronically) + Instability (chronically) N.B. Patella spontaneously relocates

BIOLOGY OF THE MENISCUS Medial Meniscus Medial Meniscus Semilunar Semilunar Narrow anteriorly Narrow anteriorly Adherent to MCL Adherent to MCL Lateral Meniscus Lateral Meniscus Circular Circular Covers more of tibia Covers more of tibia Uniform size Uniform size Less adherent Less adherent

TYPES OF MENISCUS TEARS Longitudinal Longitudinal Horizontal Horizontal Oblique Oblique Radial Radial

MENISCAL INJURIES HISTORY Mechanism = pivot, twist Mechanism = pivot, twist + heard a “pop” + heard a “pop” - locking, instability - locking, instability Effusion hours later Effusion hours later

MENISCAL INJURIES PHYSICAL EXAM Joint line tenderness Joint line tenderness IR/ER IR/ER Decreased ROM Decreased ROM McMurray’s test McMurray’s test Apley’s compression test Apley’s compression test

ASSORTED KNEE PROBLEMS Osgood-Schlatter Syndrome Osgood-Schlatter Syndrome Patellar, Quad Tendinitis Patellar, Quad Tendinitis Plica Plica Iliotibial Band Syndrome Iliotibial Band Syndrome

TENDINITIS QUADRICEPS AND PATELLAR History History Pain with: Pain with: Jumping Jumping Stairs Stairs Prolonged sitting Prolonged sitting Mechanism = overuse Mechanism = overuse

TENDINITIS QUADRICEPS AND PATELLAR Physical Exam Physical Exam Tender superior/inferior pole of patella Tender superior/inferior pole of patella Tender tibial tubercle Tender tibial tubercle Tight hams, Achilles, quads Tight hams, Achilles, quads Pain with resisted action of muscle Pain with resisted action of muscle

TENDINITIS QUADRICEPS AND PATELLAR Treatment P: protection, pain meds R: rest I: ice C: compression E: elevation S: support, strength/stretch exercises

BURSITIS Treatment Treatment NSAID’s NSAID’s Ice Ice Flexibility exercises Flexibility exercises Steroid injections Steroid injections Surgery for chronic cases (prepatellar) Surgery for chronic cases (prepatellar)