History and examination of the knee

Mark BlythConsultant Orthopaedic SurgeonGlasgow Royal Infirmary

PAINPatellofemoralPoorly localisedAnteriorAntero-medialAntero-lateralPosteriorBilateralWorse stairs, hills, sitting, start up, squatting

Medial/lateral joint lineWell localisedSingle finger

Referred painFrom hip

From spine

SWELLING

EffusionSuprapatellar swellingBoth hands

Not effusionInfrapatellar swellingSingle finger

FragmentaryHard lumpLocalised to joint line

Extra-articularLocationBursae, meniscal cysts etc

GIVING WAYUnstable ligamentKnee gives outPivoting sensationSignif after effect – swelling and disabilityNo patternDifficulties with uneven ground

PFJ/ pain quads inhibitionPreceding ant knee painFrequentNo after effectsAss PFJ activitiesHyperextension sensationAss patellar click

Patellar instabilityHistory of patellar dislocationPatellar clunkSwelling possible

LOCKINGTrue meniscal lockingBlock to extensionMed/lat localised painUnlock several minutes+/- swellingAss squattingRotation to relieve

Pseudolocking PFJOccurs at 300

TransientFrequentNo swelling

Loose bodyNot activity specificNot transientKnee immobile several minutes

Poss palpable fragment

HISTORY OF INJURYCruciate injuryHeard/felt popImmed swellingContact/ non-contact sportStopped playing

Complex ligament injuryHigh energy mechanismContact sportSwelling disproportionate to pain

Meniscal injuryHistory of squattingTwisting injuryDelayed swelling

PFJ injuryDirect blow patellaImmed swelling

Ant/post drawerLachmansMCL/LCL laxityPLC laxityPivot shift

Joint line tendernessPostmed and lat tendernesss

LOOK FEEL MOVE TEST

STAND

SIT

SUPINEEXTN

SUPINE 20-900

HIP EXAMINATION

NEUROVASCULAR EXAMINATION

WalkAnt/postAlignmentScars/sinusesWastingSwelling/effusion

Patellar tracking on extensionLag on extension

Flexion contractureScars/sinusesWastingSwelling/effusion

Crepitus on extension

Quads mechanism tenderness

Confirm passive ROM

SquattingKneeling

Pain on resisted extension

Foot lift testPatellar stress testPatellar restraint test

Ligament evaluation

ACL

Difficult in the acute phase/ anxious patient+/- EUA

Lachman (Jonsson 1982, Torg 1976)Beware PCL false positivePivot shift may be negative

PCL

Posterior drawer test at 900

Grade 1 0-5mm (tibial condyles anterior)Grade 2 5-10mm (condyles in line)Grade 3 10+mm (tibial condyles posterior)

Grade 3 suspect collateral injury

Valgus stress at 300

Grade 1 0-5mmGrade 2 5-10mmGrade 3 10+mmGrade 3+ Valgus in extn

MCL/posteromedial corner

Grade 3+ suspect posteromedialcorner and cruciate injury

Varus stress at 300

Grade 1 0-2mmGrade 2 5-10mmGrade 3 10+mm

Dial testat 300 only Posterolateral cornerat 300+900 PCL+posterolateral cornerReverse pivot shift testHughstons hyperextension ext rotation test

LCL/posterolateral corner

Grade 2+3 suspectposterolateral injury

Clinical examination

Inverted J sign

Perch point 300

Clinical examination

Q angle > 20 degrees significant

Thank you