1. Dan Bertheau, NP, MPH Orthopaedic Trauma Institute SFGH/UCSF NP/CNM/PA PROFESSIONAL PRACTICE GROUP CITY & COUNTY OF SAN FRANCISCO APRIL 21, 2011 CONFERENCE Knee Examination

2. DISCLOSURE I have no relevant financial disclosures related to topics in this lecture

3. KNEE EXAM- TOPICS Anatomy Three Typical Conditions History Physical Exam Tests Diagnostics Red Flag/Emergent/Urgent Referrals Physical Exam

4. KNEE ANATOMY www.aclsolutions.com

5. KNEE ANATOMY www.aclsolutions.com

6. THREE TYPICAL CONDITIONS DJD Ligament Injury ( ACL- most common ) Meniscus Injury

7. Mechanism of Injury Duration Walking Tolerance (# blocks) Range of Motion (~0-140) Locking? (unable to fully extend- r/o Bucket Handle) Edema Neurovascular Sensation Motor Previous Treatment (success/failure) Assistive Devices HISTORY

8. PAIN Anterior- Patella & Associated Soft Tissues Medial- Meniscus, OA Lateral- Iliotibial Band Friction, Meniscus, OA Posterior- Meniscus, Baker’s Cyst

9. KNEE DJD

10. LACHMAN- ACL Snider, R.

11. ANTERIOR DRAWER- ACL Snider, R.

12. MRI – NORMAL ACL – SAGITTAL VIEW Helms, C. A.

13. MRI – ACL RUPTURE – SAGITTAL VIEW

14. VARUS STRESS- LCL VALGUS STRESS- MCL www.aafp.org

15. POSTERIOR SAG- PCL Snider, R.

16. MCMURRAY TEST- MENISCUS

17. MRI – MENISCAL TEAR – SAGITTAL VIEW

18. MENISCUS TEAR www.leadingmd.com

19. X-RAY IMAGING ***WEIGHT BEARING*** AP Tibiofemoral Joint LAT Patellofemoral Joint Rosenberg (Bent Knee PA) Tibiofemoral Joint Sunrise (Merchant, Axial) Patellofemoral Joint

20. MRI IMAGING Order Plain X-Rays First R/O Soft Tissue Injury Do Not Order In Patient With Known DJD

21. LAB CBC with Differential ESR CRP

22. RED FLAG/EMERGENT/URGENT Knee Dislocation Septic Knee Acute Fractures Bucket Handle Tear of Meniscus

23. REFERRAL- LESS THAN IDEAL “knee pain”

24. REFERRAL- IDEAL “64 year old male with several years of progressive right knee pain; less than 2 block walking tolerance for last 6 months; failed NSAIDs; started PT 3 months ago; Jan 2011 WB x-rays = arthritic changes; interested in op & non-op options”

25. PATIENT HANDOUTS PCP “Bridge” to Physical Therapy Online (in the future)

26. REFERENCES Atlas of Human Anatomy, 2 nd Edition, Netter, Frank, 2003, Icon Learning Systems Essentials of Musculoskeletal Care, Snider, Robert K., Ed.,2003, American Academy of Orthopedic Surgeons Fundamentals of Skeletal Radiology, 2 nd Ed., Helms, Clyde A., 1995, W. B. Saunders Orthopaedist’s Guide to Plain Film Imaging, Pavlov, H., Burke, M., Giesa, M., Seager, K.R., White, E.T.,1999, Thieme Medical Publishers Orthopedic Physical Assessment, 4 th Ed., Magee, David J., 2002, Elsevier Sciences Physical Examination of the Spine & Extremities, Hoppenfeld, Stanley, 1976, Appleton-Century-Crofts

27. Thank You!