Christina Allen, M.D. - UCSF · PDF fileChristina Allen, M.D. Assistant Professor UCSF Sports...
Transcript of Christina Allen, M.D. - UCSF · PDF fileChristina Allen, M.D. Assistant Professor UCSF Sports...
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KNEE PHYSICAL EXAM
Christina Allen, M.D.Christina Allen, M.D.Assistant Professor
UCSF Sports MedicineDepartment of Orthopaedic SurgeryUniversity of Calif., San Francisco
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History• What, How, When did
the injury happen?• Where does it hurt?• Did you hear/feel a
“pop?”• Swelling? If so,
immediate or delayed?• Locking, or inability to
go through a FROM?
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Knee Physical Exam-General• Standing Alignment: varus, valgus?• Range of Motion-symmetric?• Squat ability, pain with squat (where)?• Swelling/effusion?• Quadriceps Function/ atrophy• Patellofemoral Exam• Ligament Exam• Palpation for tenderness: Joint Line, other• Flexion McMurray’s• Examine Hips, Back – look for “zebras”
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ACL Injury• Add nml and inj MRI
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ANTERIOR DRAWER TEST• Hip flexed at 45°, knee flexed at 90°• With both thumbs placed on the joint
line, the tibia is gently drawn forward.• Excursion of the tibia is compared with
the unaffected side.
SENSITIVITY SPECIFICITY41% 95%
Katz and Fingeroth, 1986
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ANTERIOR DRAWER TESTANTERIOR DRAWER TEST
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LACHMAN’S TEST
• 15° - 30° of knee flexion
• The femur is stabilized with one hand and the tibia is gently drawn forward with the opposite hand.
• (+) = Anterior translation of the tibia with a “soft” or “mushy” endpoint
SENSITIVITY SPECIFICITY82% 97%
Katz and Fingeroth,1986
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VARIATIONS OF THE LACHMAN TEST
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PIVOT SHIFT TEST• Tibia is internally rotated and axially loaded
while applying a gentle valgus stress to the knee. Start at full extension.
• Knee is then slowly brought into flexion.
• (+) = “Shift” felt with subluxation/ reduction of the lateral tibial plateau anteriorly as the knee is brought into further flexion at ~30°
SENSITIVITY SPECIFICITY81% 98%
Katz and Fingeroth, 1986
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PIVOT SHIFT PIVOT SHIFT TESTTEST
Galway RD, Beaupre A, MacIntosh DL:
Pivot Shift: A Clinical Sign of Symptomatic Anterior Cruciate Insufficiency
J Bone Joint Surg [Br] 54: 763-764, 1972
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PCL Injury
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PCL Injury
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POSTERIOR SAG SIGNPOSTERIOR SAG SIGN• Knee is placed in a resting position
at 90° of flexion.• (+) = “Sag” posteriorly. • Compare with the opposite side.
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POSTERIOR DRAWER TESTPOSTERIOR DRAWER TEST• Hip flexed at 45°, knee flexed at 90°• With both thumbs placed on the
joint line, the tibia is gently pushed posteriorly.
• Excursion of the tibia is compared with the unaffected side.
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QUAD ACTIVE TESTQUAD ACTIVE TEST• Eyes at the level of the patient’s
flexed knee• Foot is stabilized by the examiner’s
hand (or sit on foot) • Patient is asked to gently slide the
foot down the table. • (+) = tibial displacement anteriorly
(due to quadriceps contraction)
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Daniel, DM et al: Use of the quadriceps active test to diagnose posterior cruciate ligament disruption and measure posterior laxity
of the knee, J Bone Joint Surg (AM) 70-386-391, 1988.
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PosteroLateral Corner Injury• Mechanisms:• Isolated injury rare- usually injury occurs
with PCL or multiligament injury• Knee hyperextension with varus stress
(posterolateral force directed vs. proximal tibia with knee at or near full extension)
• Hyperextension +/- external rotation• Severe varus stress or ext. rotation of tibia• Injury to LCL, popliteus, biceps insertion on
fibula, IT band, varus smaller PL ligaments
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PosteroLateral Corner Injury
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PLC Injury
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LCL Injury• Mechanisms:• varus force applied to the interally rotated,
flexed knee• Isolated injury rarer than MCL injuries• More common to see combined with PCL
injury or as part of posterolateral corner injury
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LCL Injury
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LCL Injury
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VARUS STRESS TESTS• A Varus stress is applied both in full extension
and in 20-30 ° of flexion• Test in extension checks for injury of
posterolateral corner structures (may see some laxity with isolated LCL injury)
• Test in flexion evaluates LCL• Grading of Injury based on Jt. Space opening:
Grade I: 0 to 5 mmGrade II: 6 to 10 mmGrade III: 11 to 15 mm
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VARUS STRESS TEST
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PLRI- Dial test
• Patient may be tested supine or prone• Side to side difference > 15° abnormal• Test at 30 and 90 degrees of flexion• ↑
External rotation at 30° : Isolated PLS inj
• ↑
External rotation at 30°, 90°: PLS+PCL inj
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PLRI- Dial test
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MCL Injury• Mechanisms:• valgus force applied to the flexed knee• Occasionally caused by forced ER of tibia • ruptures or sprains frequently involve
attachment to the medial femoral condyle• May be associated with tears of the PM
capsule, the ACL, and the medial meniscus • A contusion/ fx due to impact of the lateral
femoral condyle or lateral tibial plateau is common (bone bruise with lateral pain)
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MCL Injury
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MCL Injury
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MCL Injury
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VALGUS STRESS TESTS• A Valgus stress is applied both in full extension and in
20-30 ° of flexion• Test in extension checks for injury of posteromedial
corner structures (capsule, connections of semimembranosus)
• Test in flexion evaluates MCL• Grading of Injury based on Jt. Space opening:
Grade I: 0 to 5 mmGrade II: 6 to 10 mmGrade III: 11 to 15 mm
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VALGUS STRESS TEST
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MCL Instability
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Meniscal Injury
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JOINT LINE TENDERNESSJOINT LINE TENDERNESS• Palpation of the anterior, middle,
and posterior parts of both the medial and lateral joint spaces.
SENSITIVITY SPECIFICITY85% 30%
Fowler and Lubliner, 1989
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MCMURRAY’S TEST• Knee is flexed and placed in external
rotation• Examiner applies a valgus or varus
force• Knee is then extended. • (+) = Pain and/or a popping/ snapping
sensation.SENSITIVITY SPECIFICITY29% 96%
Fowler and Lubliner, 1989
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MCMURRAYMCMURRAY’’S S TESTTEST
McMurray TP: The Semilunar Cartilages.
Br J Surg 29: 407-414, 1942
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Thessaly Test
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APLEY’S TEST• Patient prone, knee bent to 90 °. Push down on sole
of the foot toward the examination table.
• Tibia is rotated both externally and internally
(DISTRACTION)
• The tibia is then distracted while being rotated once more.
• (+) = Patient experiences decreased pain with the distraction maneauver as compared to the compression maneuver
SENSITIVITY SPECIFICITY16% 80%
Fowler and Lubliner, 1989
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APLEYAPLEY’’S TESTS TEST
Apley AG: The Diagnosis of Meniscus Injuries.
J Bone Joint Surg 29: 78-84, 1947
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Patella Dislocation
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Patellofemoral Instability• Mechanism:• femoral internal rotation on a fixed,
externally rotated tibiaoften a twisting injury38% during athletics (ER + valgus)
• Direct blow to knee• Acute hemarthrosis
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MRI - PF Instability
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• Generalized ligamentous laxity
• Anatomic alignment• Foot
Hyperpronation• Quadriceps tone
(esp. VMO)
Evaluation - PF instability
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Evaluation - PF instability• Q- angle• J-tracking• Patellar
tenderness• Patellar mobility
(tilt, glide)• “Apprehension”
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Patellar Apprehension Sign