History and examination of the knee Mark Blyth Consultant Orthopaedic Surgeon Glasgow Royal Infirmary
Mar 26, 2015
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