1. The Knee: Clinical Evaluation Nick Iannuzzi, MD November 28 th - 2011

2. Outline Anatomy History Differential Diagnoses – Structured Evaluation Practice Physical Exam 2

3. The Knee 3

4. 4

5. Exam Maneuvers Anterior drawer test Lachman test Pivot shift test Posterior sag sign Posterior drawer test Quadriceps active test Valgus stress test Varus stress test Patellofemoral grind test Apprehension test Joint line tenderness McMurray Test Apley grind test Bounce home test 5 WHAT? WHY? WHEN?

6. History  Timing?  Mechanism?  Pain description?  Swelling?  Mechanical Symptoms?  Instability? Baker et al 1983; Hughston et al 1985, Laprade et al 1997

7. Differential Diagnoses Anterior Knee pain Extensor mechanism rupture/failure Patellofemoral pain Patellofemoral instability Plica Arthritis 7

8. Differential Diagnoses Lateral knee pain Lateral meniscal tear IT band friction syndrome Segond fracture LCL/PLC tear Gastrocnemius strain/tear Arthritis 8

9. Differential Diagnoses Medial Knee Pain Medial meniscus tear MCL strain/tear Hamstring strain/tear Pes anserine bursitis MPFL disruption Arthritis 9

10. Differential Diagnoses Posterior knee pain Popliteal/Baker’s cyst (meniscal tear) Tumors Claudication Radiculopathy 10

11. Differential Diagnosis Locked knee Meniscal tear OCD lesion (femur/patella) Tibial spine avulsion Osteochondroma (tendons incarcerated) 11

12. Rule #1 Always compare to the other Knee!! INTERNAL CONTROL

13. EXAM-Getting Started Inspection/Palpation -Effusion? -Tender? -Skin Breaks? Alignment -Varus/Valgus? -Dislocated? Range of Motion (0-130+) -Mechanical Block -Contractures -Crepitus “Seek Out Disease, Don’t Hope For Health”-anonymous WHAT DO YOU SEE??

14. EXAM-Overview Inspection/Palpation Alignment Range of Motion (0-130+) Tracking Extensor Mechanism Stability -Provocative Tests GAIT Analysis

15. ACL – Anterior Drawer 15 Knee at 90 degrees Anteriorly translate the tibia with thumbs palpating relationship between femoral condyles and tibia Sensitivity 22-41% (acute injuries); 50-95% (chronic injuries)

16. ACL - Lachman Exam  Position: -Supine -Knee flexed 0-15 deg  Force Applied: Anterior  Grading Scale: Grade I: 1-5mm Grade II: 6- 10mm Grade III: >10mm Sens 80-99%, Spec 95% Gross Anterior Displacement: ACL+PLC Hamstrings Relaxed Feel for Endpoint

17. ACL - Pivot Shift  Position: -Supine -Knee Extension  Flexion  Force: Valgus, IR  Pathomechanics: -SUBLUXED  Reduced - ITT reduces tibia @ 20-30 flexion  Pathoanatomy: -Positive: Glide, Shift, Gross Sens 35-99%, Spec 98% *Key Testable Exam Finding

18. PCL – Posterior Sag Sign Position supine –Hip flexed 45 degrees –Knee flexed 90 degrees Normally, tib plateau extends 1cm beyond femoral condyles Sens 79%, Spec 100% 18

19. PCL - Posterior Drawer  Position: -Supine -Knee flexed 90 deg  Force Applied: Posterior  Pathomechanics: -Post translation tibial plateau -Tibial Plat comp to Femoral Condyle  Pathoanatomy: -G I/II  PCL injury -G III  PCL + PLC injury Sens 50-100%, Spec 99% Negative in all normal knees, Cooper 1991 Gollehon et al 1987, Grood et al 1988, Noyes 1996

20. Varus/Valgus Stress  Position: -Supine -Knee 0/30 deg flexion  VALGUS: -0 deg  MCL + ACL/PCL -30 deg  MCL  VARUS: -0 deg  LCL +Cruciate/IT/Bicep -30 deg  Pop/PFL/Lat cap Negative in all normal knees, Cooper 1991

21. PLC/PCL - ER stress (Dial)  Position: -Prone -Hip Neutral (0 deg flexion) -Knee Flexed 30/90  Force: ER  Pathomechanics: -Tibial ER on Femur  Pathoanatomy: >10 deg of Asymmetry 30 deg  PLC Injury 90 deg  PLC + PCL Injury TMA-Transmalleolar Axis Negative in all normal knees, Cooper 1991

22. PLC/PCL - External Rotation Recurvatum  Position: -Supine -Hip neutral (0 deg flexion) -Knee extended  Force: Lift FF anterior  Pathomechanics: -Knee hyperextends -External rotation -Varus  Pathoanatomy: -PLC injury - ±PCL/ACL tear Negative in all normal knees, Cooper 1991

23. Meniscus – Joint Line Tenderness Can palpate medial and lateral joint lines of tibia at ~90 degrees flexion Medial meniscus more prominent with IR Lateral meniscus more prominent with ER Sens 55-85%, Spec 30- 67% 23

24. Meniscus – McMurray’s Hyperflex knee –Hold heel in one hand –Hold knee with other –Internally rotate knee while extending to 90 degrees –Externally rotate knee while extending to 90 degrees –Can apply varus/valgus stress Sens 16-58%, Spec 77-98% 24

25. Patellofemoral Instability – Q angle Angle formed by –Line drawn from ASIS to center of patella –Line drawn from center of patella to tibial tubercle –Normal is 10-15 deg 25

26. Patellofemoral Instability – Apprehension Sign Leg hanging off table, supported by thigh Knee flexed 30 degrees Attempt lateral translation of patella Positive sign results when patient flexes quad to resist translation Sens 39% 26

27. Vascular Exam Pulses -Popliteal -Dorsalis Pedis -Posterior Tibial  Capillary Refill/Warmth Ankle/Brachial Index: ≥0.9 NPV 100% <0.9 PPV 90%, Miranda: 35 knee dislocations Exam :100% NPV ->Popliteal injury -Serial Exams over 24hrs POSITIVE: Angiography or OR!!

28. KNEE Emergencies? INFECTION DISLOCATION VASCULAR INJURY -Dislocations -Distal femur/Prox Tibia Most knee complaints are NOT emergencies!!

29. Surgical Problems PathologyFinding ACL  Lachmans Meniscus  McMurray’s Arthritis  Hx/Xray Infection  Pain/Effusion/Labs Vascular  ABI/Hard Signs

30. CONCLUSIONS HISTORY EXAMINE NL KNEE R/O EMERGENCY REPETITION IS KEY PHONE A FRIEND 30 IT IS ONLY A VIRTUE IF YOU’RE NOT A SCREWUP!