1. Musculoskeletal Curriculum History & Exam of the Injured Knee

2. 2 Goal Learn a standardized, evidence-based history and physical examination of patients with knee injuries WHICH WILL : Enable family medicine resident physicians to accurately diagnose common knee problems throughout the full age spectrum of patients seen in family medicine

3. 3 Competency-Based Objectives Patient care – focused history and exam Professionalism – respect, compassion Interpersonal and communication skills – differential diagnosis Medical knowledge base – anatomy, injury mechanisms Systems based practice – accuracy, time-efficiency

4. 4 Assessing a knee injury Components of the assessment include Focused history Attentive physical examination Thoughtfully ordered tests/studies (for future discussion)

5. Focused History

6. 6 Focused History Questions Onset of Pain Date of injury Character/nature of pain Location of pain* Anterior Medial Lateral Posterior

7. 7 Focused History Questions 2 Mechanism of Injury – helps predict injured structure Contact or noncontact injury?* If contact, what part of the knee was contacted?  Anterior blow?  Valgus force?  Varus force? Was foot of affected knee planted on the ground?** Valgus alignment = distal segment deviates lateral with respect to proximal segment. Patellas Touch http://moon.ouhsc.edu/dthompso/namics/varus.gif

8. 8 Focused History Questions 3 Injury-Associated Events Pop heard or felt? Swelling after injury (immediate vs delayed) Catching / Locking Buckling / Instability (“giving way”)

9. 9 Instability - Example http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocat ion.JPG Patellar dislocation

10. 10 Focused History Questions 4 Degree of Immediate Dysfunction |------  ------  ------  ------  | Unable to Antalgic Continued Ambulate Gait* to Participate History of Prior Knee Injuries or Surgeries

11. 11 Historical Clues to Knee Injury Diagnosis Noncontact injury with “pop”ACL tear Contact injury with “pop”MCL or LCL tear, meniscus tear, fracture Acute swellingACL tear, fracture, knee dislocation Lateral blow to the kneeMCL tear Medial blow to the kneeLCL tear Knee “gave out” or “buckled”ACL tear, patellar dislocation Fall onto a flexed kneePCL tear

12. Physical Exam

13. 13 Physical Exam - General Develop a standard routine Alleviate the patient's fears GENERAL STEPS Inspection Palpation Range of motion Strength testing Special tests

14. 14 Physical Exam - Exposure Adequate exposure - groin to toes bilaterally Examine in supine position Compare knees

15. 15 Observe – Static Alignment Patient stands facing examiner with feet shoulder width apart Ankles, subtalar joints – pronation, supination Feet – pes planus, pes cavus (http://www.steenwyk.com/pronsup.htm) Pes planusPes cavus (http://www.arc.org.uk/about_arth/booklets/6012/images/6012_1.gif)

16. 16 Patient then brings medial aspects of knees and ankles in contact Knees – genu valgum (I), genu varum (II) Observe – Static Alignment (http://www.orthoseek.com/articles/img/bowl1.gif) Genu valgumGenu varum

17. 17 Observe – Dynamic Alignment Pronation/Supination may be enhanced with ambulation Antalgic gait indicates significant problem (anti = against, algic = pain)

18. 18 Inspect Knee Warmth Erythema Effusion* Evidence of local trauma Abrasions Contusions Lacerations Patella position Muscle atrophy

19. 19 Inspect Knee-Related Muscles Quadriceps atrophy Long-standing problem Vastus medialis atrophy After surgery http://www.neuro.wustl.edu/neuromuscular/pics/people/patients/Hands/ibmquadatrsm.jpg

20. 20 Normal Knee – Anterior, Extended

21. 21 Surface Anatomy - Anterior, Extended Patella Hollow Indented

22. 22 Normal Knee – Anterior, Flexed

23. 23 Surface Anatomy - Anterior, Flexed Head Of Fibula Patella Tibial Tuberosity

24. 24 Palpation – Anterior* Patella: Lateral and Medial Patellar Facets Superior And Inferior Patellar Facets Patellar Tendon** Lateral Fat Pad Medial Fat Pat

25. 25 Surface Anatomy - Medial Medial Femoral Condyle Patella Joint Line Medial Tibial Condyle Tibial Tuberosity

26. 26 Palpation - Medial Medial Collateral Ligament (MCL)* Pes anserine bursa** Medial joint line

27. 27 Surface Anatomy – Lateral Patella Head Of Fibula Tibial Tuberosity Quadriceps

28. 28 Palpation – Lateral* Lateral joint line Lateral Collateral Ligament (LCL)**

29. 29 Palpation - Posterior Popliteal fossa Abnormal bulges Popliteal artery aneurysm Popliteal thrombophlebitis Baker’s cyst

30. 30 Range Of Motion Testing Extension Flexion 0º 135º Describe loss of degrees of extension Example: “lacks 5 degrees of extension,” or “extension = minus 5 degrees” Locking* = patient unable to fully extend or flex knee due to a mechanical blockage in the knee (i.e., loose body, bucket-handle meniscus tear)

31. 31 Special Tests – Anterior Knee Pain Patellar apprehension test* Patellofemoral grind test**

32. 32 Special Tests - Ligaments Assess stability of 4 knee ligaments via applied stresses* Anterior Cruciate Posterior Cruciate Lateral Collateral Medial Collateral

33. 33 Stress Testing of Ligaments 2 Use a standard exam routine Direct, gentle pressure No sudden forces Abnormal test 1. Excessive motion = laxity What is NORMAL motion?* 2. Soft/mushy end point**

34. 34 Collateral Ligament Assessment Patient and Examiner Position*

35. 35 Valgus Stress Test for MCL* Note Direction Of Forces

36. 36 Video of Valgus Stress Test Click on image for video

37. 37 Varus Stress Test for LCL* Note direction of forces

38. 38 Video of Varus Stress Test Click on image for video

39. 39 Lachman’s Test* Patient Position Physician hand placement

40. 40 Lachman’s Test 2 View from lateral aspect* Note direction of forces

41. 41 Video of Lachman’s Test Click on image for video

42. 42 Alternate Lachman’s Test Click on image for video

43. 43 Anterior Drawer Test for ACL Physician Position & Movements* Patient Position Note direction of forces

44. 44 Posterior Drawer Testing- PCL* Note direction of forces

45. 45 Assess Meniscus – Knee Flexion Most sensitive test is full flexion* Examiner passively flexes the knee or has patient perform a full two-legged squat to test for meniscal injury Joint line tenderness** Flexion of the knee enhances palpation of the anterior half of each meniscus

46. 46 No Evidence to Support Pivot-Shift* - for ACL tear McMurray Testing**- for meniscus tears