Transcript Examination of the Knee - Athletic Training at Iowa

Examination of the Knee
Thursday SM Conference
August 21, 2008
Exam Settings
1. Sideline
2. Training room
3. Office/clinic
(on the field triage)
(post game eval)
(delayed + detailed)
The golden period
(Golden opportunity…for good exam)
• Fleeting minutes of minimal pain
• No swelling
• No muscle spasm
The golden period
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After soft tissue injuries
After initial shock of injury
Duration is 10-15 minutes
Maximum patient cooperation
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?)
Case Presentation
22 year old collegiate wrestler
Contact injury to left knee
Medial-sided knee pain
Sideline Exam Routine
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Determine mechanism
Point of maximum tenderness
Maneuver producing most pain
Determine severity of damage
• Mechanism ?
– Foot planted
– Outside force
– Pain + “pop”
Sideline Exam
• Pain “on inside”
Medial Pain
(Differential Diagnoses)
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Medial Collateral Ligament sprain
Hamstring strain
Gastroc strain
Medial Meniscus 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
II “Moderate”
Lax with end-point
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”
Lax with end-point
III “Severe”
Gross laxity
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
=
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=
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
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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 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.
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