1. Knee & Hip Examinations Family Medicine Academic Day Marie-Josée Klett, MD CCFP Dip Sport Med Louise Walker, MD CCFP FCFP Dip Sport Med Department of Family Medicine University of Ottawa

2. Confidentiality and Conflict Declaration Speakers have no conflicts of interest to declare This presentation and associated handouts are for use by University of Ottawa DFM residents and are not to be used for other purposes or distributed without the written consent from the speakers

3. Knee History Role play

4. Knee History Nature of the problem – pain, swelling, catching/locking, giving way Duration Mechanism of injury Location of pain Radiation of the pain Aggravating factors Relieving factors Pain during and/or after activity Rx to date; Past Hx; ROS; FHx; Meds; Allergies; “Other”-reason for visit at this time; sporting history; legal

5. LOOK Standing: Alignment Knee: Normal, Recurvatum, Holds in Flexion Varus (finger distance between knees) Valgus (intermalleolar distance) Deformity Visible swelling front or popliteal space Feet: Pes planus, Pes cavus, Overpronation

6. Alignment

7. Feet

8. Overpronation

9. Baker’s cyst

10. LOOK Walking: Gait:Antalgic favours: Right or Left Varus thrust PWBNWB AIDS: crutches/cane/w/c

11. LOOK Sitting Skin - Redness/Blueness/Mottled/Abrasions/Scar/E cchymosis Muscle – contract quads- Lateral Tracking (“J” Sign) Tibia:Internal Rotation External Rotation

12. FEEL Palpate Point(s) of Maximal Tenderness: Bones: joint lines (knee bent), femoral condyles (knee bent), patellar facets, tibial plateau/tubercle, fibula Ligaments: MCL, LCL Tendons: Patellar, Quad, Hamstring, ITB, Pes Anserine Can also feel soft tissue swelling and muscle bulk (atrophy)

13. Surface Anatomy: Practice Pes Anserine

14. MOVE Range of Motion: Active, Passive, Resisted Extension Flexion Feel for Crepitus (retropatellar during active flexion/extension) Hip screen: at least passive Flex + IR + ER (Ext/Abd/Add if abnormal)

15. Special Tests Meniscus Ligaments Patella

16. Meniscus: Anatomy

17. Meniscus: History Usually specific incident: most often twisting injury Often associated with swelling, can have catching and/or locking Pain with squatting, kneeling, twisting Medial or lateral pain but sometimes difficult to localise

18. Meniscus: Physical Exam Often have small to medium effusion: bulge test http://www.youtube.com/watch?v=LsgutijmX7 U Pain with passive flexion OR 2.3 Joint line tenderness Sens 76% Spec 29%

19. Meniscus: Physical Exam McMurray: externally rotate and abduct for medial, internally rotate and adduct for lateral, click with pain is positive.(Sens 52% Spec 97%) Thessaly: twist on affected knee with 20 o of flexion, pain is positive. (Sens 96% Spec 95%) Apley Grind: patient prone, apply load to knee and grind, pain is positive. (Very little data)

20. Meniscus: Thessaly

21. Practice Passive flexion and extension Bulge test McMurray’s Thessaly’s

22. Ligaments: Anatomy

23. MCL: Anatomy

24. ACL: Anatomy

25. Ligaments: History Mechanism of injury: –Collaterals: valgus or varus force –ACL: plant and twist, hyperextension or quick deceleration –PCL: direct anterior force on bent knee (dashboard injury or fall onto tibia of flexed knee) May have heard/felt a pop ACL: immediate large swelling Feeling of instability

26. MCL/LCL: Physical Exam LOOK – soft-tissue swelling FEEL - tenderness over ligament TEST- at 0 and 20 degrees-test for pain and laxity to differentiate grade of injury

27. PCL: Physical Exam Mild to moderate effusion May not have any palpable tenderness but can feel step-off Posterior Sag/Posterior drawer test

28. PCL: Posterior Sag

29. PCL: Posterior Drawer

30. ACL Physical Exam: Hemarthrosis: large effusion (patellar tap) May have associated meniscal or MCL tear Can have avulsion fracture lateral tibial plateau so tenderness there common Lachman (15-30 o flexion) most sensitive and specific knee test, Anterior Drawer, Pivot Shift (if MCL intact and no meniscus tear) Anterior drawer: Sens 48% Spec 87% Pivot shift: Sens 61% Spec 97% (but only studied by its developers) Lachman’s: Sens 87% Spec 93%, LR+ 42.0

31. ACL: Lachman’s

32. Practice Lachman’s (or Drop Leg Lachman’s) MCL & LCL Collateral tests (at 0 and 20) Posterior Drawer

33. Patella: Anatomy

34. Patella: History Anterior knee pain Often worse going down stairs, squatting, kneeling Sometimes pain will cause quads inhibition- patients get giving way

35. Patella: Physical Exam Look for contributing biomechanical factors: genu valgus, femoral anteversion, pes planus/overpronation Tender patella facettes, retropatellar crepitus J-sign Assess patella: Laxity/apprehension, compression/Osmond-Clark Assess for correctable factors: –Tightness: hamstrings, IT Band (Ober’s) –Strength: VMO, abductors

36. Patella: Obers

37. Practice Palpation of patellar facets J-sign Laxity/apprehension Compression test Ober’s Hip Abductor strength

38. HIP ASSESSMENT HISTORY Chief Complaint: Mechanism of injury: Duration: Location:LateralAnterior Other - “C” SIGN Radiation:GroinButtocks Thigh Other Severity when most severe: (0 to 10) Catching: When does pain occur? (rest; sitting; walk; run; stairs up/down; uneven ground; in/out car; during activity; after activity; morning; afternoon; night; other relation to bowel bladder, menses): Relieving Factors: Treatment to date: Past history of knee injury or related hx: Other medical history: Medication: Allergies:

39. Hip: Location of Pain

40. HIP: PHYSICAL EXAMINATION LOOK FEEL MOVE SPECIAL TESTS

41. LOOK Standing: Alignment Walking: Antalgic favours: RightLeft Trendelenburg PWBNWB AIDS: crutches/cane/w/c

42. LOOK Lying: Swelling Muscle wasting Flexion deformity Position

43. FEEL Palpate points of maximal tenderness: Bones: ASIS, Greater trochanter and bursa, Pubic ramus and symphysis, Ischial tuberosity, SI joints Muscles & Tendons: Adductors, IT band (TFL), gluteus minimus/maximus, piriformis, Hamstring Abdomen and Lumbar Spine if indicated

44. Hip bones

45. Hip Muscles

46. “Glutes” and GT Bursae Piriformis Glut Minimus GT Bursa of Glut Medius Glut Medius GT Bursa of Glut Maximus Glut Maximus

47. Practice Bones: –Greater trochanter –Pubic Symphysis –Anterior Inferior and Superior Iliac Spine –Ischial tuberosity –SI joints Muscles: –Piriformis

48. MOVE Hip Range of Motion: Active Passive Resisted Flexion: (~120°) Extension: (~20-30°) Abduction: (~45-50°) Adduction: (~20°) Internal rotation: (~35°) External rotation: (~45°)

49. Special Tests FAI or FADDIR testing: labrum/joint Trendelenburg test: abductor strength Thomas test (flexion contracture/ITB tightness) FABER: Pain (groin, lateral, SI) Functional tests: Hop on Rt and Lt (pain?)

50. Flexion-adduction-internal rotation test (FAI)

51. Trendelenburg test

52. Thomas test

53. FABER

54. Back: Special Tests Back ROM: FlexionExtension Lateral flexionRotation Sacro-iliac Kinetic Test Leg Lengths: Rt_____cm.Lt_____cm.

55. Practice Passive IR FAI test Trendelenburg test Thomas test FABER

56. Thank You!