Knee Pain and the Knee Exam February 21, 2013 Kate Lupton, MD.
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Transcript of Knee Pain and the Knee Exam February 21, 2013 Kate Lupton, MD.
Knee Pain and the Knee Exam
February 21, 2013Kate Lupton, MD
History
• Joint(s) involved• Functional limitations• ?Trauma/Injury -> Mechanism• Acute onset vs. slowly progressive• Prior problems with area• Systemic signs and symptoms
Principles of the MSK Exam
• Good exposure (clothing removed, in gown)
• LOOK• FEEL• MOVE• SPECIAL TESTS
LOOK
LOOK
• Alignment/Posture – – “Ankles together” – look at knees (genu valgus/varus)– “Ankles shoulder width apart” – look at arches (pes
planus/cavus, tibial torsion)– “Turn around” – look at heel alignment, back of knees
– heel valgus/varus, Baker’s cyst
• Gait – heel/toe walk, squat• Knee – “SEADS” = swelling, erythema, atrophy,
deformity, scars
LOOK
FEEL
• Find point maximal tenderness• ?Reproduce sx• Effusion – patellar ballotment• Patella – check mobility, tenderness under
lateral, medial, inferior facets. Apprehension – knee flexed to 20°, laterally deviate patella. If involuntary quad contraction -> positive sign
• Joint line – palpate MCL, LCL, meniscal cyst• Posterior knee – muscle insertions, Baker cyst
FEEL
FEEL
Patellar Ballotment• Flex knee• Hand on supra-patellar
pouch, push down toward patella
• Push down perpendicularly on center of patella
• If effusion – patella floats and “bounces” back when pushed
FEEL
Joint line palpation• slightly flex knee• Run fingers up tibia, will
“drop” into joint line• Can flex/extend to
confirm• Feel along medial and
lateral joint lines
MOVE
• Active and passive flexion/extension• ROM – flex to 130-150°, extend 0-15°• Hyperflexion, hyperextension• Crepitus – hand over patella while
flexing/extending• Resisted active flexion/extension• Neurovascular exam – motor, sensory, reflexes,
cap refill, pulses• Hip/back screen – log roll leg, straight leg raise
MOVE
SPECIAL TESTS
• Menisci – joint line tenderness, hyperflexion/extension, McMurray
• Ligaments – Lachman, drop Lachman, anterior/posterior drawer, posterior sag, valgus/varus stress
SPECIAL TESTS
SPECIAL TESTS - Menisci
Joint line palpation• slightly flex knee• Run fingers up tibia, will
“drop” into joint line• Can flex/extend to
confirm• Feel along medial and
lateral joint lines
SPECIAL TESTS - MenisciMcMurray’s – medial
meniscus• Opposite hand grasps knee
w/ fingers on medial JL (L hand grasps R knee)
• Same hand grasps heel (R hand grasps R heel), flex knee past 90°
• Turn ankle so foot and knee point outward (heel toward compartment tested)
• Slowly extend knee to 90°, if positive test, feel palpable thud. Pain localizing to JL is also positive sign
• Sens 29%, spec 95%
SPECIAL TESTS - MenisciMcMurray’s – lateral meniscus• Opposite hand grasps knee
w/ fingers on medial JL (L hand grasps R knee)
• Same hand grasps heel (R hand grasps R heel), flex knee
• Turn ankle so foot and knee point inward (heel toward compartment tested)
• Slowly extend knee to 90°, if positive feel palpable thud. Pain localizing to JL is also positive sign
• Sens 29%, spec 95%
SPECIAL TESTS - Ligaments
Medial Collateral Ligament • Flex knee to 20-30°• One hand on inner
calf/ankle• Push inward (valgus
stress) on lateral knee while applying outward stress with hand on calf/ankle
• Positive test = joint laxity
SPECIAL TESTS - Ligaments
Lateral Collateral Ligament • Flex knee to 20-30°• One hand on outer
calf/ankle• Push outward (varus
stress) on medial knee while applying inward stress with hand on calf/ankle
• Positive test = joint laxity
SPECIAL TESTS - LigamentsLachman’s (ACL)• patient supine, knee at 20-
30° flexion• Fix femur with one hand, lift
tibia forward with other hand (force perpendicular to plane of tibia)
• Slight external rotation of foot
• Anterior force should be applied near posteromedial aspect of proximal tibia
• Positive if tibia subluxes anteriorly and concavity of patellar tendon becomes convex
• Sens 82%, spec 97%
SPECIAL TESTS - LigamentsDrop Lachman (ACL)• Better for big legs/small
hands• Patient lies with leg
abducted off side of table, flexed 25°
• Stabilize foot between examiner’s legs
• Hold femur on table with one hand
• Use opposite hand to anteriorly sublux tibia
• More sensitive than Lachman as less hamstring recruitment
SPECIAL TESTS - Ligaments
Posterior Sag (PCL)• Patient lies supine, hip
flexed to 45° and knees to 90°
• Positive if absence of tibial tubercle prominence due to posterior shift of tibia
SPECIAL TESTS - Ligaments
Posterior Drawer (PCL)• Patient supine with knee
bent to 90°• Sit on foot, grasp below
knee with both hands, thumbs on anterior tibial tuberosity
• Push backward – if intact PCL, feel distinct endpoint
• If PCL disrupted, tibia feels unrestrained in posterior translocation
SPECIAL TESTS – patellofemoral pain and chondromalacia
• Slightly flex knee• Push down on patella
with both thumbs – pain if chondromalacia
• Hold patella in place with hand, direct patient to contract quadriceps, forcing inferior surface of patella onto femur – elicits pain if chondromalacia
Many thanks to:
Anthony Luke, MD – UCSFCharlie Goldberg, MD – UCSD