Musculoskeletal Curriculum History & Physical Exam of the Injured Knee

Copyright 2005

Authors
Kathleen Carr, MD Madison Residency Program
Kathleen.Carr@fammed.wisc.edu

Dennis Breen, MD Eau Claire Residency Program

Dennis.Breen@fammed.wisc.edu

Dan Smith, DO
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Contributors
Marguerite Elliott, DO Jeff Patterson, DO Jerry Ryan, MD

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
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Competency-Based Objectives
  

Patient care focused history and exam Professionalism respect, compassion Interpersonal and communication skills
differential diagnosis

Medical knowledge base

mechanisms

anatomy, injury

Systems based practice accuracy, time-efficiency

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Assessing a knee injury



Components of the assessment include

  

Focused history Attentive physical examination Thoughtfully ordered tests/studies



for future discussion

Focused History

Focused History Questions



Onset of Pain


Date of injury or when symptoms started

Location of pain*
   

Anterior Medial Lateral Posterior

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Focused History Questions



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
http://moon.ouhsc.edu/dthompso/namics/varus.gif
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Focused History Questions



Injury-Associated Events*


Pop heard or felt? Swelling after injury (immediate vs delayed) Catching / Locking Buckling / Instability (giving way)
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Instability - Example
Patellar dislocation

http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocat ion.JPG

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Focused History Questions

 Degree

of Immediate Dysfunction

|------ ------ ------ ------ |

Unable to Ambulate Antalgic Gait* Continued to Participate

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Focused History Questions



Aggravating Factors


Activities, changing positions, stairs, kneeling

Relieving Factors/treatments tried



Ice, medications, crutches

History of previous knee injury or surgery

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Historical Clues to Knee Injury Diagnoses

Noncontact injury with pop Contact injury with pop Acute swelling ACL tear MCL or LCL tear, meniscus tear, fracture ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation MCL tear LCL tear ACL tear, patellar dislocation PCL tear
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Lateral blow to the knee Medial blow to the knee Knee gave out or buckled Fall onto a flexed knee

Physical Exam

Physical Exam - General

 

Develop a standard routine* Alleviate the patient's fears

GENERAL STEPS
Inspection Palpation Range of motion Strength testing Special tests
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Physical Exam - Exposure



 

Adequate exposure - groin to toes bilaterally Examine in supine position Compare knees

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Observe Static Alignment


 

Patient stands facing examiner with feet shoulder width apart

Ankles, subtalar joints pronation, supination Feet pes planus, pes cavus

Pes planus
(http://www.steenwyk.com/pronsup.htm)

Pes cavus
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(http://www.arc.org.uk/about_arth/booklets/6012/images/6012_1.gif)

Observe Static Alignment



Patient then brings medial aspects of knees and ankles in contact



Knees genu valgum (I), genu varum (II)

Genu valgum Genu varum

(http://www.orthoseek.com/articles/img/bowl1.gif)

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Observe Dynamic Alignment

Pronation/Supination may be enhanced with ambulation Antalgic gait indicates significant problem (anti = against, algic = pain)
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Inspect Knee
 Evidence


of local trauma
Abrasions  Contusions  Lacerations

  

Warmth Erythema Effusion*

 Patella

position  Muscle atrophy

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Inspect Knee-Related Muscles




Quadriceps atrophy
Long-standing problem




Vastus medialis atrophy

After surgery

http://www.neuro.wustl.edu/neuromuscular/pics/people/patients/Hands/ibmquadatrsm.jpg
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Normal Knee Anterior, Extended

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Surface Anatomy - Anterior, Extended*

Patella Indented Hollow

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Normal Knee Anterior, Flexed

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Surface Anatomy - Anterior, Flexed

Patella

Tibial Tuberosity

Head Of Fibula

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Palpation Anterior*
Patella: Lateral and Medial Patellar Facets

Superior And Inferior Patellar Facets Lateral Fat Pad Medial Fat Pat

Patellar Tendon**
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Surface Anatomy - Medial

Tibial Tuberosity Joint Line Medial Tibial Condyle Patella Medial Femoral Condyle

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Palpation - Medial
Medial Collateral Ligament (MCL)*

Pes anserine bursa** Medial joint line

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Surface Anatomy Lateral

Quadriceps Patella

Tibial Tuberosity Head Of Fibula

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Palpation Lateral*

Lateral Collateral Ligament (LCL)** Lateral joint line

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Palpation - Posterior


Popliteal fossa* Abnormal bulges

  

Popliteal artery aneurysm Popliteal thrombophlebitis Bakers cyst

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Range Of Motion Testing



Extension 0

Flexion 135

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)
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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

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Special Tests Anterior Knee Pain



Patellar apprehension test*

Starting position

Push patella laterally

(http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lateral%20patellar%20 apprehension.htm)

Patellofemoral grind test**

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Special Tests - Ligaments

Anterior Cruciate Posterior Cruciate

Assess stability of 4 knee ligaments via applied stresses*

Medial Collateral Lateral Collateral

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Stress Testing of Ligaments


 

Use a standard exam routine

Direct, gentle pressure No sudden forces

1.

Abnormal test Excessive motion = laxity

What is NORMAL motion?*

2.

Soft/mushy end point**

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Collateral Ligament Assessment

Patient and Examiner Position*

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Valgus Stress Test for MCL*

Note Direction Of Forces

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Video of Valgus Stress Test

Click on image for video

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Varus Stress Test for LCL*

Note direction of forces

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Video of Varus Stress Test

Click on image for video

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Lachman Test*
 

Patient Position Physician hand placement

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Lachman Test2


View from lateral aspect*

Note direction of forces

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Video of Lachman Test

Click on image for video

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Alternate Lachman Test

Click on image for video

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Anterior Drawer Test for ACL

 

Physician Position & Movements* Patient Position

Note direction of forces

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Posterior Drawer Testing- PCL*

Note direction of forces

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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

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Tests that we do not recommend routinely



Pivot-Shift* - for ACL tear McMurray Test**- for meniscus tears

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Review of Evidence ACL*

(Jackson JL, et al.)

  

Lachman Test Anterior Drawer Pivot Shift Test

Sens 87% Spec 93% Sens 48% Spec 87% Sens 61% Spec 97%
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Review of Evidence - Meniscus

(Jackson JL, et al.)

 

Joint Line Tenderness McMurray Test

Sens 76% Spec 29% Sens 52% Spec 97%

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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;68:907-12. Ebell MH. A Tool for Evaluating Patients with Knee Injury. Family Practice Management. March 2005:67-70. Jackson JL, OMalley PG, Kroenke K. Evaluation of Acute Knee Pain in Primary Care. Ann Intern Med. 2003;139:575-588. 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;84:592-603. 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;286:16101620.
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Video of Knee Exam

http://inside.fammed.wisc.edu/education/musculo

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