1 / 25

Knee Pain and the Knee Exam

Knee Pain and the Knee Exam. February 21, 2013 Kate 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.

crispin-holley
Download Presentation

Knee Pain and the Knee Exam

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Knee Pain and the Knee Exam February 21, 2013 Kate Lupton, MD

  2. History • Joint(s) involved • Functional limitations • ?Trauma/Injury -> Mechanism • Acute onset vs. slowly progressive • Prior problems with area • Systemic signs and symptoms

  3. Principles of the MSK Exam • Good exposure (clothing removed, in gown) • LOOK • FEEL • MOVE • SPECIAL TESTS

  4. LOOK

  5. LOOK • Alignment/Posture – • “Ankles together” – look at knees (genuvalgus/varus) • “Ankles shoulder width apart” – look at arches (pesplanus/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

  6. LOOK

  7. 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

  8. FEEL

  9. 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

  10. 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

  11. 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

  12. MOVE

  13. SPECIAL TESTS • Menisci – joint line tenderness, hyperflexion/extension, McMurray • Ligaments – Lachman, drop Lachman, anterior/posterior drawer, posterior sag, valgus/varus stress

  14. SPECIAL TESTS

  15. 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

  16. SPECIAL TESTS - Menisci McMurray’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%

  17. SPECIAL TESTS - Menisci McMurray’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%

  18. 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

  19. 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

  20. SPECIAL TESTS - Ligaments Lachman’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 subluxesanteriorly and concavity of patellar tendon becomes convex • Sens 82%, spec 97%

  21. SPECIAL TESTS - Ligaments Drop 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 anteriorlysublux tibia • More sensitive than Lachman as less hamstring recruitment

  22. 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

  23. 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 tibialtuberosity • Push backward – if intact PCL, feel distinct endpoint • If PCL disrupted, tibia feels unrestrained in posterior translocation

  24. 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

  25. Many thanks to: Anthony Luke, MD – UCSF Charlie Goldberg, MD – UCSD

More Related