1. Examination of the Knee Thursday SM Conference August 30, 2007

2. Exam Settings 1.Sideline Exam (on the field triage) 2.Training room (post game eval) 3.Office/clinic Exam (delayed + detailed)

3. Sideline Exam Purpose: determine disposition 1.Transfer (severe injury) 2.Hold out(mild – moderate) 1.Observe + re-examine 2.Provide first aide 3.Return to action (mild ?– no injury?)

4. Sideline Exam Routine Determine mechanism Point of maximum tenderness Maneuver producing most pain Determine severity of damage

5. Case Presentation 22 year old collegiate wrestler Contact injury to left knee Medial-sided knee pain

6. Mechanism ? –Foot planted –Outside force –Pain + “pop”

7. Sideline Exam Pain “on inside”

8. Medial Pain (Differential Diagnoses) Medial Collateral Ligament sprain Hamstring strain Gastroc strain Medial Meniscus tear

9. First… find Joint line

10. Maximum Tenderness? Pain “on inside” Tender over MCL

11. Most Painful maneuver? Straight Valgus? –Straight –30 degrees External rotation?

12. Sprain Severity? Classify by laxity Best exam technique –One-handed –Two handed

13. Check both sides! Laxity normal ??? –“Plastic man” –Post exercise

14. Anterior Drawer at 20-30 degrees “Modified Lachman’s”

15. Exam Settings 1.Sideline Exam (on the field triage) 2.Training room (post game eval) 3.Office/clinic Exam

16. Two handed technique Trap ankle on Iliac crest Both hands on joint line –Palpate both joint lines

17. Sprains (ligaments)

20. Hughston Laxity Classification Grade I – 1-4 mm laxity Grade II – 5-9 mm laxity Grade III – >10 mm laxity (soft endpoint) »Hughston JC, Andrews JR, Cross MJ, Moschi A: Classification of knee ligament instabilities. Part I. The medial compartment and cruciate ligaments. »J Bone Joint Surg Am 58:159-172, 197

21. Two handed technique Trap ankle on Iliac crest Both hands on joint line –Palpate both joint lines

22. Two handed technique

23. Collegiate football Severity vs. Return Grade I – 10.6 days Grade II – 19.5 days Derscheid, G.L. and J.G. Garrick. MCL injuries in football: Non-operative management of grade I and grade II sprains. Am J Sports Med, 1981. 9(6): p. 365-8.

24. Sideline estimate ( Crowley-Albright 30 consecutive FB cases) 1 mm = 1 week 2 mm = 2 weeks 3 mm = 3 weeks 6 mm = 6 weeks

25. Time Loss From Sport Severity of injury Compliance??

26. Exam Settings 1.Sideline Exam (on the field triage) 2.Training room (post game eval) 3.Office/clinic Exam

27. Office Exam What is important about the MCL exam? –Knee stability in full extension

28. Knee Hemarthrosis Differential Diagnosis ACL70% Meniscus50% Fracture20% Patellar dislocation PCL

29. Value of MRI? When should an MRI be done? –When knowledge of location of injury might influence treatment –When additional injury is suspected Instability at full extension should increase suspicion of cruciate injury »Mazzocca, A.D., et al., Valgus medial collateral ligament rupture causes concomitant loading and damage of the anterior cruciate ligament. »J Knee Surg, 2003. 16(3): p. 148-51.

30. Location MCL Tissue damage Proximal ruptures heal more quickly than distal but have more stiffness Complete ruptures can displace into the joint Damage over entire ligament associated with persistent laxity after non-operative treatment –Nakamura, N., S. Horibe, et al. (2003). "Acute grade III MCL injury of the knee associated with ACL tear. usefulness of MRI in determining treatment regimen." –Am J Sports Med 31(2): 261-7.

31. Grade III – Gross instability Laxity at full ext (no endpoint) Indicates complete rupture of MCL –Evaluate posteromedial capsule –Evaluate for cruciate injury ACL PCL –Evaluate for Patellar Dislocation

32. Pivot shift techniques Re-entry tests –MacIntosh –Hughston Jerk Exit tests –Losee (5 tests) –Slocum –Low profile

33. The “Pivot-Shift” “Low Profile” Technique “exit” type pivot (in-to-out of place) No valgus Limit arc to last 20 degrees

34. Losee Tests See video

35. Active Quad Self Induction of Pivot Shift

36. LCL??? or MCL???

37. Reverse pivot Ask patient “In or out?”

38. Meniscus tears Joint line tenderness –Most sensitive but least specific (Fu) Squat and duck walk test McMurray' s test –Modified McMurray' s test –Most sensitive but least sensitive Appley’s test –Modified Appley’s test Full Extension?? –Pain anterior joint line

39. Modified McMurray' s test

40. Displaced Meniscus? (bucket-handle tear) Lacks full extension –No screw home –Pain anterior joint line –Rotation affects degree of pain Lacks full flexion –Rotation affects degree of pain Rotation OK in mid range flexion

41. Anterior knee pain Osgood Schlatter' s Jumper’s knee P-F Chondromalacia Synovitis (Plica?) P-F instability