Transcript Examination of the Knee - Athletic Training at Iowa
Examination of the Knee
Thursday SM Conference August 30, 2007
Exam Settings
1. Sideline Exam (on the field triage) 2. Training room (post game eval) 3. Office/clinic Exam (delayed + detailed)
Sideline Exam
Purpose: determine disposition 1. Transfer 2. Hold out
(severe injury) (mild – moderate)
1. Observe + re-examine
2. Provide first aide
3. Return to action (mild ?
– no injury?)
Sideline Exam Routine
• • • •
Determine mechanism Point of maximum tenderness Maneuver producing most pain Determine severity of damage
Case Presentation
22 year old collegiate wrestler Contact injury to left knee Medial-sided knee pain
• Mechanism ?
– Foot planted – Outside force – Pain + “pop”
Sideline Exam
• Pain “
on inside
”
Medial Pain
(Differential Diagnoses) • • • •
M
edial
C
ollateral
L
igament sprain
H
amstring strain
G
astroc strain
M
edial
M
eniscus tear
First… find Joint line
Maximum Tenderness?
• Pain “
on inside
” • Tender
over MCL
Most Painful maneuver?
•
Straight Valgus?
– Straight – 30 degrees •
External rotation?
Sprain Severity?
• •
Classify by laxity Best exam technique
– –
One-handed Two handed
Check both sides!
• Laxity normal ???
–
“ Plastic man ”
– Post exercise
Anterior Drawer at 20-30 degrees “Modified Lachman’s”
Exam Settings
1. Sideline Exam (on the field triage) 2. Training room (post game eval) 3. Office/clinic Exam
Two handed technique
• Trap ankle on Iliac crest • Both hands on joint line – Palpate both joint lines
Sprains (ligaments)
I “Mild” Pain but no laxity Lax with end-point II “Moderate” III “Severe” Gross laxity
Sprains (ligaments)
I “Mild” Pain but no laxity II “Moderate” Lax with end-point III “Severe” Gross laxity
Sprains (ligaments)
I “Mild” Pain but no laxity II “Moderate” III “Severe” Lax with end-point Gross laxity
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
Two handed technique
• Trap ankle on Iliac crest • Both hands on joint line – Palpate both joint lines
Two handed technique
Collegiate football
Severity vs. Return • Grade I – • Grade II – 10.6 days 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
.
Sideline estimate (
Crowley-Albright
30 consecutive FB cases) 1 mm 2 mm 3 mm 6 mm = = = = 1 week 2 weeks 3 weeks 6 weeks
Time Loss From Sport
• • Severity of injury
Compliance??
Exam Settings
1. Sideline Exam (on the field triage) 2. Training room (post game eval) 3. Office/clinic Exam
Office Exam
• What is important about the MCL exam?
–
Knee stability in full extension
Knee Hemarthrosis Differential Diagnosis
• ACL • Meniscus • Fracture • Patellar dislocation • PCL 70% 50% 20%
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
.
Location MCL Tissue damage
• • •
Proximal ruptures
heal more quickly than distal but have more stiffness
Complete ruptures
into the joint can displace
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
.
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
Pivot shift techniques
• •
Re-entry tests
– –
MacIntosh Hughston Jerk Exit tests
– – –
Losee (5 tests) Slocum Low profile
The “Pivot-Shift”
“Low Profile” Technique
• “exit” type pivot (in-to-out of place) • No valgus • Limit arc to last 20 degrees
Losee Tests
See video
Active Quad Self Induction
of Pivot Shift
LCL??? or MCL???
Reverse pivot
• Ask patient “In or out?”
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
Modified
McMurray' s test
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
range flexion in mid
Anterior knee pain
• Osgood Schlatter' s • Jumper’s knee • P-F Chondromalacia • Synovitis (Plica?) • P-F instability