9/24/2012 1 Welcome! Pignon, Haiti IS IT…. GOOD MORNING LORD! OR GOOD LORD, MORNING! PRINCIPLES OF EXAMNINIG THE KNEE Greg Bennett, PT, DSc Excel Physical Therapy Marymount University Rules Hx often diagnostic Least to most threatening Sx trump exam Develop consistent routine Don’t inflame inflamed tissue “If we agree on everything, one of us is unnecessary”
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9/24/2012
1
Welcome! Pignon, Haiti
IS IT…. GOOD MORNING LORD! OR GOOD LORD, MORNING!
PRINCIPLES OF EXAMNINIG THE KNEE
Greg Bennett, PT, DSc
Excel Physical Therapy
Marymount University
Rules Hx often diagnostic
Least to most threatening
Sx trump exam
Develop consistent routine
Don’t inflame inflamed tissue
“If we agree on everything, one of us is unnecessary”
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2
EXAMINATION GOALS
1. ESTABLISH OR CONFIRM DIAGNOSIS
2. ESTABLISH TREATMENT
3. LIMIT PROGRESSION
4. BASELINE PATIENT STATUS
KEYS TO SUCCESS
HISTORY
THOROUGHNESS/
ACCURACY
KNOWLEDGE of ANATOMY and MECHANICS
EXPERIENCE
HISTORY OF INJURY
Adequate history taking can often be diagnostic; include discovery of previous injuries.
ACUTE HISTORY
Mechanism of injury/ knee position
Pop, snap or click?
Swelling-onset
Post-injury function
CHRONIC HISTORY
History of injury
Onset during what?
Noisy knee?
Locking/ buckling
Stairs painful?
ADL/sports
Swelling/pain
CURRENT SYMPTOMS
Swelling
Instability
Pain
Dysfunction
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SWELLING
When
How much?
EFFUSION
Rapid: Major trauma vascular tissue injury
Gradual: PFJS, DJD,
tendonitis, chronic instabilities
SYMPTOM ONSET
Sudden-trauma Sudden-no trauma
Gradual- no trauma Gradual-trauma
POSSIBILITIES: Sudden Onset: Trauma
Meniscal tear
Collateral ligament strain or sprain.
ACL or PCL tear
Fracture
TF or PF Dislocation
POSSIBILITIES: Sudden Onset: No Trauma
Neoplasm
Sub-clinical injury
Overuse “Final Straw”
POSSIBILITIES: Gradual onset: no trauma
Meniscus
Subluxation or dislocation
PFJS, DJD, tendonitis
Impingement; Plica
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POSSIBILITIES: Gradual onset: trauma
Grade I or II Sprain/Strain
Subluxation
PFJS, DJD
Impingement
PAIN-beware of correlations (no absolutes)
Sudden: Trauma: major injury
Prolonged sitting: PFJS, AKPS
Stairs/squats: PFJS, tendonitis ACL deficiency
Changing direction: Instability; subluxation; meniscal lesions
PAIN CORRELATIONS
Locking, popping
Grating, cracking
Sharp
Dull
Morning pain
With activity
Meniscus
PFJS
Many
PFJS, instability
DJD
Synovitis/tendonitis
Mechanism of Injury: Associated Mechanics
ACL INJURIES
Cutting, twisting
Hyperextension
Deceleration
POSTERIOR LATERAL CORNER
Lateral collateral is a pencil-like cord
Popliteus tendon
The capsule here is open, weak and
prone to injury
Together with the anterior cruciate
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PCL INJURIES
Direct blow
Hyperflexion
MCL INJURY
Valgus stress
Weight bearing, foot fixed
“CKC”
LCL INJURY
Varus stress
Weight bearing, foot fixed
“CKC”
PATELLA INJURIES
Direct blow
Twisting, cutting
MENISCAL INJURIES
Twisting, cutting
Weight bearing
Categorizing Injuries
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FIRST DEGREE SPRAIN
Mild symptoms
Min. tender
Normal motion
Re-occurs
Min. tearing
SECOND DEGREE SPRAIN
Mod. Symptoms
Loss of function
Loss of motion
Unstable
Becomes arthritic?
Partial tear
THIRD DEGREE SPRAIN
Severe symptoms
Loss of unction
Marked loss of motion
Unstable
Arthritis
Complete tear
INTERPERTATION
R/O referral
Scan spine
Analysis
Confirmation
Diagnosis
Problem list (goals)
Physical Examination OBSERVATION
Gait/ activities
Posture
Deformity/ alignment
Swelling
Atrophy
Rubor/redness
Stress
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PALPATION
Calor/temperature
TTP
Swelling
Sensation
Structure/ patella
Pulses
Crepitus
LIGAMENT TESTS
Varus/valgus
Drawer
Lachman
Pivot shift/RPS
Meniscal
TEST SENSITIVITY
Sensitivity is a statistical measure of how well a classification test correctly identifies a condition
Sensitivity is one measure of how good a test is.
It is the number of "true positives" plus "false negatives," divided by the percent of cases picked up by the test.
Test Specificity
Specificity: Are you testing what you think you are testing?
Specificity is a statistical measure of how well a test correctly identifies the negative cases, or those cases that do not meet the condition under study.
It is defined as the number of "true negatives" plus the number of "false positives" divided by the percent of negative results that are really negative.
Special Tests - ACL Injury Lachman Test
Lachman’s Test
“Gold Standard”
30˚ flexion
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Lachman’s Test
Sensitivity Range: 60-100%
Specificity Range: 100%
Sources: Dehaven 80; Donaldson 85; Liu 95; others
Anterior Drawer
Less sensitive
45 hip flexion˚
90 knee flexion˚
Anterior Drawer
Sensitivity Range: 10-76%
Specificity Range: 50-86%
Influenced by secondary restraints
Sources: Dehaven 80; Rubenstein 94; Torg 76; Kim 95; others
PIVOT SHIFT: Functional Indicator
START
– Extension
– IR
– Valgus
ITB dependent
PIVOT SHIFT
FINISH
– Flexion
– IR
– valgus
PIVOT SHIFT
Sensitivity Range: 27-71%
Specificity Range: 89-100% (Torg)
Influenced by secondary restraints
Sources: Galway 80; Rubenstein 94; Torg 76; Donaldson 85; others
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REVERSE PIVOT SHIFT: ACL and PCL stressed
START
– Flexion
– ER
– Valgus
MCL+dependent
REVERSE PIVOT SHIFT
FINISH
– Extension
– ER
– valgus
REVERSE PIVOT SHIFT
Poorly Studied (Rubenstein 94)
Sensitivity: 26%
Specificity: 95% (PCL)
Influenced by secondary restraints
Varus/Valgus stress for LCL and MCL Injury
Valgus Stress: MCL
At 30˚ flexion, the cruciates are in their most relaxed state, and pathologic laxity palpated is capsular laxity
Medial capsular layers provide stability to valgus stresses at knee & are primary stabilizer at 0-30˚ of flexion
Varus Stress: LCL
Role of LCL increases w/ joint flexion, as posterolateral structures become lax
With joint flexion, resistance by ACL decreases, but large forces are found in PCL at 90 degrees of flexion
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Valgus/Varus Stress: Repeated at 0 Degrees
If still lax at 0, what does that mean?
Secondary restraints also injured. What are they?
Meniscii MCL/LCL Capsule Muscles?
MENISCAL TESTS
McMurray (1942)
Thessaly test (2009)
Apley Grind
Point tenderness
Scans
Thessaly Test
Supports the patient holding outstretched hands while the patient stands flatfooted.
Patient then rotates their knee and body, internally and externally, three times
Keep knee flexed at 20 degrees.
Suspected meniscal tears will experience joint-line discomfort.
Clin J Sport Med. 2009 Jan;19(1):9-12
Thessaly Test
Sensitivity 90.3%
Specificity 97.7%
Positive predictive value of 98.5%
Negative predictive value of 86.0%
Clin J Sport Med. 2009 Jan;19(1):9-12
MENISCAL TESTS
Sensitivity Range: 29-63%
Specificity Range: 29-57%
Influenced by numerous tissues
Sources: Anderson 86; Boeree 91; Fowler89; Noble 80; others
MENISCAL TESTS
Pain in the posterior aspect of the knee with maximal flexion
may be indicative of a posterior horn meniscal tear.
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Special Tests - PCL Injury Posterior Drawer Test
Sag Sign
Quad-Active Test
TIBIAL SAG (DROPBACK): PCL
Tibial drop back test: the examiner compares the prominence of the
proximal tibia to the femoral condyles with the knee flexed to 80°
Also done with hips/knees at 90˚
TIBIAL SAG (DROPBACK): PCL
Poorly Studied: Rubenstein 94
Sensitivity Range: 79%
Specificity Range: 100%
Anterior Knee Pain
Most common knee complaint
Need to discern between patellar
– pain
– instability
– both pain and instability
Patello-Femoral Exam
Lower Extremity Alignment Generalized Laxity Locations of Tenderness Patellar Alignment Passive Patellar Tilt Lateral and Medial Patellar Glide
Patellar Apprehension Crepitation Q angle at 90 degrees
Passive Patellar Tilt
Lifting the lateral border of the patella superiorly to assess the tightness of the lateral patellar-femoral retinaculum
Inability to achieve horizontal is a positive test (excessively tight lateral structures)
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Patellar Glides
Lateral Patellar Glide
– Manually sliding the patella laterally
– Apprehension sign: when a lateral patellar glide produces fear of dislocation
Medial Patellar Glide
– Manually sliding the patella medially
Patellar Glide Test
Q Angle
Defined as the angle between – the axis of the femur to the center of the patella
– the center of the patellar to the tibial tubercle
Assessment in flexion is more significant
Assessed in full knee extension and at 30 and 90º of knee flexion
An increased Q angle increases the likelihood of lateral patellar subluxation
Patellar Instability
Lateral patellar subluxation or dislocation
knee flexion
tibial external rotation
valgus
Etiologies:
an increased Q angle in early flexion
incompetent MPFL
shallow trochlea
short trochlear groove (relative alta)
Radiographs
Lateral Radiograph
– Patellar Height
Blumenstaat’s line
Physeal scar
Lateral Radiograph
Insall-Salvati Ratio – Defined as the
length of the patella in relation to the length of the patellar tendon
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PTs Management of Patellofemoral Problems
Differentiate between pain and instability
Instability:
-Provide pt with a patellar sleeve , preferably one with a lateral patellar support
-Initiate therapy referral for ROM ,quad strengthening and hip ER strengthening
PATELLOFEMORAL TESTS
Perkins Sign (posterior palpation)
Grind (2 angles)
AROM crepitance
Cinema sign
Clarkes sign
PATELLOFEMORAL ASSESMENT
Stability
Orientation
Muscle Function
Crepitation
Irritation
SPECIAL TESTS
Girth
Ballotment
Bounce home
Q angle
Alta/ baja patella
SPECIAL TESTS
Diagnostic Imaging
X-ray
MRI
CT Scan
ACTIVE MOTION
Deficits
Quality
Crepitance
Apprehension
Squatting??
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PASSIVE MOTION
Deficits
End feel
Painful arc
Crepitance
Joint play
Flexibility
End Feel!
RESISTED MOTIONS
Contractile vs. non-contractile
Interpretation
EXERCISE DYNAMOMETERS
Not diagnostic
Usually not appropriate with acute injury
GENERAL HEALTH
Hypermobility
Joint conditions
Neurology
Medications
Injections/steroids
GENERAL HEALTH
Allergies
Infections
Weight
Mental status??
History CA
Outcomes Measures
LYSHOLM KNEE RATING SCALE
Tegner Scale
Cincinnati Scale
Etc.
Adult population, orthopedics
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CONCLUSIONS
MUSCULOSKELETAL EXAMINATION
History
Active Movements
Passive Movements
Resisted Movements
Palpation
Specific Orthopedic Tests
X-Ray
Correlation
Treatment plan
Thank You!
Pignon,
Haiti
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