Physical Exam of the Knee Inspection Palpation Range of Motion Special tests Neurovascular assessment

INSPECTION Effusion Q angle Erythema Angular deformities Ecchymosis Edema Q angle Angular deformities Muscular asymmetry

PALPATION ANTERIOR MEDIAL Tibial tubercle Infrapatellar tendon Quad insertion Patellar facets Crepitus ? MEDIAL MCL Meniscus Pes anserine insertion Tibial plateau Femoral condyle

PALPATION LATERAL POSTERIOR Head of the fibula LCL Meniscus Tibial plateau Femoral condyle Gerdy’s tubercle POSTERIOR Menisci (posterior horns) Popliteal fossa Hamstring tendons

ACL Special Tests Anterior drawer Lachman test Pivot shift test Valgus stress test at full extension!

Grading Ligament Injuries

ACL: PHYSICAL EXAM Decreased ROM Effusion-hemarthrosis, immediate + Instability tests Lachman: most accurate Pivot shift Anterior drawer + MCL and meniscus tests

Translation + ENDPOINTS! LIGAMENT EXAM Translation + ENDPOINTS!

Ligamentous Instability Valgus stress may sprain or tear the medial collateral ligament. Varus stress may sprain or tear the lateral collateral ligament. Both of these stresses with a rotational force may sprain or tear the anterior and/or posterior cruciate ligaments.

Ligamentous Instability Clinical Signs and Symptoms Knee pain Limited range of motion Difficulty in weight bearing Joint effusion Knee giving out; chronic unstable knee

MCL INJURIES HISTORY Mechanism = valgus stress Medial joint line pain Lack of large effusion Difficulty weight-bearing

MCL INJURIES PHYSICAL EXAM Tender to palpation along MCL Pain + instability with valgus stress 30o flexion = MCL 90o flexion = associated ACL Pain with Apley’s distraction test COMPARE SIDES

PCL INJURIES Mechanism Effusion (less than with ACL) Sports = fall on flexed knee with foot plantarflexed, hyperextension, pivot MVA = dashboard injury Effusion (less than with ACL) Shifting/instability (chronic) Less distinctive

PCL INJURIES PHYSICAL EXAM + Effusion + Posterior drawer test + Posterior sag sign False positive Lachman test Common to have isolated injuries

PATELLAR INSTABILITY Acute patellar dislocation Acute patellar subluxation Patellar tracking dysfunction

PATELLAR DISLOCATION History Mechanism = pivot Immediate effusion May visualize patella dislocated laterally + Instability (chronically) N.B. Patella spontaneously relocates

PATELLAR DISLOCATION Physical Exam Tender peripatellar structures Medial retinaculum Lateral femoral condyle Effusion ? Patella dislocated laterally Xrays- osteochondral fracture, effusion

PATELLAR DISLOCATION Treatment Knee extension immobilizer x 4 wks Early quad setting exercises PRE’s at 4 wks to pain tolerance Return to sport Full, painless ROM Normal strength Adequate aerobic fitness

MENISCAL INJURIES History Mechanism = pivot, twist + heard a “pop” Effusion- 12-36o after injury Mechanical Sxs- locking, instability

Meniscus Instability Clinical Signs and Symptoms Local medial or lateral joint pain Limited knee range of motion Crepitus upon movement Joint effusion Knee buckling Pain on walking up and down stairs Pain on squatting

MENISCAL INJURIES Physical Exam Joint line tenderness IR/ER Decreased ROM McMurray’s test Apley’s compression test

Apley’s Compression Test Procedure: Patient prone. Flex leg to 90 degrees. Grasp the patient’s ankle and apply downward pressure while you internally and externally rotate the leg. Positive Test: Flexing the knee distorts the meniscus. Downward pressure further stresses the meniscus. Pain or crepitus on either side indicates a meniscus injury on that side.