Knee examination

Anatomy

Look Feel Move: Special tests Active Passive ROM: Extension= 0 to -10° Flexion= 130-150°

Special tests Sag sign Posterior/anterior drawer McMurray’s Lachman’s Valgus/Varus stress Patellar apprehension

Examine the joint above and below! Don’t forget the other knee. Neurovascular integrity X-ray 2 views, MRI and aspiration are the investigation options. What investigations?

History Traumatic: Where is the pain? Mechanism of injury: Pyrexial? Was there a pop? Immediate or delayed swelling Ability to weight bear and carry on activity Joint instability Pyrexial? Occupation Non traumatic also include: Morning stiffness, pain after exercise. Tick bites Recent infections (including sexually transmitted diseases) Hx of Gout/psoriasis Pop suggests ligament tear or fracture

A 32 year old man twisted his knee while skiing A 32 year old man twisted his knee while skiing. Although his knee was painful he managed to complete the run. By the next morning his knee was visibly swollen. On examination there was reduced range of movement in his knee and he was tender over the medial joint line. What is the most likely diagnosis: Medial meniscus tear Medial collateral ligament injury Lateral collateral ligament injury Haemarthrosis ACL injury

Meniscus injury Twisting injury The effusion may take some time to develop. Pain over the joint line Medial meniscus tears are far more common than lateral due to the medial meniscus being less mobile and thinner anteriorly. Healing may be slow especially if the deeper 2/3 are involved due to the poorer blood supply. Mx: Conservative= RICE Surgical= repair or meniscectomy

Medial collateral ligament injury Lateral collateral ligament injury A 22 year old male presents with a painful, swollen right knee after kicking a wall. He describes a twisting and popping feeling on impact with the wall and the knee swelled quickly. What is the diagnosis: Medial meniscus tear Medial collateral ligament injury Lateral collateral ligament injury Haemarthrosis ACL injury

Haemarthrosis

A 12 year old boy fell off his bike and hurt his left knee A 12 year old boy fell off his bike and hurt his left knee. The knee promptly swelled to twice its size and was tender. This has happened on multiple occasions and his brother has had similar admissions: Developmental hip dysplasia Genu varus Osgood-Schlatter disease Perthes disease Haemarthrosis Still’s disease Septic arthritis Transient synovitis

A 65 year old man tripped walking along a cobbled street and landed on his right knee. On examination the right knee is swollen and painful. He can walk with help however cannot straight leg raise. What is the most likely diagnosis? ACL injury PCL injury Lateral meniscus tear Medial meniscus tear OA Osteochondritis dessicans Patellar fracture RA Tibial plateau fracture

A 28 year old man presented following a kick to the side of the knee while playing football. He describes his left knee being hit from the left. Since the kick he has been unable to weight bear and his knee feels unsteady. On examination his knee is tender but is not swollen. What is the most likely diagnosis? ACL injury PCL injury Lateral meniscus tear Medial meniscus tear OA Osteochondritis dessicans Patellar fracture RA MCL injury LCL injury

LCL and MCL injury Valgus stress (outside of the knee)=MCL Varus stress (inside of the knee)=LCL Pain and knee instability O’Donoghue’s terrible triad: MCL Medial meniscus ACL

Housemaids knee/carpet fitters knee A 47 year old man presents to GP with pain and swelling directly over both patellae. He has just started a part time job as a carpet layer. On examination there is no other abnormality of the knee. What is the most likely diagnosis? ACL injury Bakers cyst Chrondromalacia patellae Medial meniscus tear OA Prepatellar bursitis RA Pellegrini-Stieda disease Osteochondritis dissecans Housemaids knee/carpet fitters knee Infrapatellar bursitis is known as clergyman’s knee (more erect position than housemaids knee)

A 60 year old lady has a 12 month history of worsening pain and swelling in her left knee for which she has been taking NSAIDs and paracetamol. On examination there is crepitus in the left knee and pain limits knee movement. A significant valgus deformity can be seen on standing. What is the most likely diagnosis? ACL injury Bakers cyst Chrondromalacia patellae Medial meniscus tear OA Prepatellar bursitis RA Pellegrini-Stieda disease Osteochondritis dissecans

OA 4 radiological findings: Osteophytes Joint space narrowing Bone cysts Subarticular sclerosis

A 14 year old boy presents with pain in his right knee that is worse when he plays football. On examination he is apyrexial but the right tibial tuberosity is enlarged and painful. What is the likely diagnosis? Developmental hip dysplasia Genu varus Osgood-Schlatter disease Perthes disease Haemarthrosis Still’s disease Septic arthritis Transient synovitis

Osgood-Schlatters Disease Osteochondritis of the tibial tuberosity where the patellar tendon attaches. Most common in active boys Pain and swelling around the tuberosity Worse with exercise particularly leg extension. Mx= rest and analgesia

A 64 year old man has a painful swollen right knee A 64 year old man has a painful swollen right knee. Symptoms began 2 days previous. There is no history of trauma. Joint aspirate shows pus cells, negatively birefringent crystals and no organisms. What is the most likely diagnosis? Reactive arthritis Pseudogout ACL injury Gout Rheumatoid arthritis

Gout Vs Pseudogout Acute inflammatory mono-arthritis Red, hot, swollen joint- aspirate to rule out septic joint NSAIDS then colchicine in an acute attack Allopurinol may be needed to prevent further attacks if >2 per year Gout Pseudogout Middle aged men Elderly women Metatarsophalangeal joint classically Knees Negatively birefringent fine needle shaped crystals Positively birefringent brick/rhomboidal shaped crystals

A 65 year old lady presents with difficulty walking on her right leg because of pain. She has a history of a right knee replacement. On examination she is pyrexial and her right knee is hot, swollen and tender. What is the most likely diagnosis? ACL injury Bakers cyst Chrondromalacia patellae Medial meniscus tear OA Prepatellar bursitis RA Septic arthritis Pellegrini-Stieda disease Osteochondritis dissecans

Bakers cyst RA!! What is this? What diseases are associated?

A 33-year-old cab driver was involved in a rear-end motor vehicle crash and hit his knee against the dashboard. He presents with a six-week history of knee pain, and difficulty walking down inclines. What is the most likely diagnosis? ACL injury PCL injury Lateral meniscus tear Medial meniscus tear OA Osteochondritis dessicans Patellar fracture RA MCL injury LCL injury

PCL tears Rare in isolation Substantial knee trauma caused by forcibly pushing the tibia back. Goalkeepers and RTAs after hitting the dashboard. Difficulty walking up and down stairs/inclines Less swelling and instability than ACL. Can be treated with rehab alone.

A 17-year-old football player sustained a noncontact knee injury while her leg was planted to make a turn. She heard a pop and felt her knee buckle. What is the most sensitive clinical test to establish the diagnosis? Posterior drawer McMurray Lachman Anterior drawer

ACL tears ACL injury typically results from rotational stress on a planted/fixed weight baring joint. POP Immediate haemarthrosis Joint instability

A 30-year-old man presents with lower back, knee, and ankle pain of two months’ duration. He also has had burning on urination. Physical examination reveals a rash over the palms and soles. Sacroiliitis is present on radiographs. The clinical diagnosis is: ankylosing spondylitis psoriatic arthropathy gonococcal arthritis reactive arthritis (Reiter’s disease)

Reiter’s syndrome A reactive arthritis (Seronegative arthropathy) Triad of conjuctivitis, urethritis and arthritis Can’t see, Can’t pee, Can’t climb a tree Often precipitated by genitourinary or gastrointestinal infections. The most common triggers are intestinal infections (Salmonella, Shigella or Campylobacter) and sexually transmitted infections (Chlamydia trachomatis) 1-2 months after the onset of arthritis, some develop keratoderma blennorrhagicum.

Weird and wonderful Pellegrini-Stieda disease- ossification of the superior part of the medial collateral ligament of the knee. Osteochondritis dissecans- causes pain and swelling of the affected joint which catches and locks during movement. Chrondromalacia patellae- inflammation of the underside of the patella and softening of the cartilage. Pain going up and down stairs from rubbing against femur. Ehlers-Danlos syndrome, Marfan’s and other connective tissue disease.

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