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Examination of the Knee

Examination of the Knee. Thursday SM Conference August 21, 2008. Exam Settings. Sideline (on the field triage) Training room (post game eval) Office/clinic (delayed + detailed). The golden period (Golden opportunity…for good exam).

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Examination of the Knee

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  1. Examination of the Knee Thursday SM Conference August 21, 2008

  2. Exam Settings • Sideline (on the field triage) • Training room (post game eval) • Office/clinic (delayed + detailed)

  3. Thegoldenperiod(Golden opportunity…for good exam) • Fleeting minutes of minimal pain • No swelling • No muscle spasm

  4. The golden period • After soft tissue injuries • After initial shock of injury • Duration is 10-15 minutes • Maximum patient cooperation

  5. Sideline ExamPurpose: determine disposition • Transfer (severe injury) • Hold out (mild – moderate) • Observe + re-examine • Provide first aide • Return to action (mild ?– no injury?)

  6. Case Presentation 22 year old collegiate wrestler Contact injury to left knee Medial-sided knee pain

  7. Sideline Exam Routine • Determine mechanism • Point of maximum tenderness • Maneuver producing most pain • Determine severity of damage

  8. Mechanism ? • Foot planted • Outside force • Pain + “pop”

  9. Sideline Exam • Pain “on inside”

  10. Medial Pain(Differential Diagnoses) • Medial Collateral Ligament sprain • Hamstring strain • Gastroc strain • Medial Meniscus tear

  11. First… find Joint line

  12. Maximum Tenderness? • Pain “on inside” • Tender over MCL

  13. Most Painful maneuver? • Straight Valgus? • Straight • 30 degrees • External rotation?

  14. Sprain Severity? • Classify by laxity • Best exam technique • One-handed • Two handed

  15. Check both sides! • Laxity normal ??? • “Plastic man” • Post exercise

  16. Anterior Drawer at 20-30 degrees“Modified Lachman’s”

  17. Exam Settings • Sideline Exam (on the field triage) • Training room (post game eval) • Office/clinic Exam

  18. Two handed technique • Trap ankle on Iliac crest • Both hands on joint line • Palpate both joint lines Stress X-ray

  19. Sprains (ligaments)

  20. Sprains (ligaments)

  21. Sprains (ligaments)

  22. Two handed technique • Trap ankle on Iliac crest • Both hands on joint line • Palpate both joint lines Stress X-ray

  23. Two handed technique

  24. Collegiate footballSeverity vs. Return • Grade I – 10.6 days • Grade II – 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.

  25. Sideline estimate(Crowley-Albright 30 consecutive FB cases) 1 mm = 1 week 2 mm = 2 weeks 3 mm = 3 weeks 6 mm = 6 weeks millimeters = weeks

  26. Time Loss From Sport • Severity of injury • Compliance??

  27. Exam Settings • Sideline Exam (on the field triage) • Training room (post game eval) • Office/clinic Exam

  28. Office Exam • What is important about the MCL exam? • Knee stability in full extension

  29. KneeHemarthrosisDifferential Diagnosis • ACL 70% • Meniscus 50% • Fracture 20% • Patellar dislocation • PCL

  30. 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.

  31. 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.

  32. Grade III – Gross instabilityLaxity at full ext (no endpoint) Indicates completerupture of MCL • Evaluate posteromedial capsule • Evaluate for cruciate injury • ACL • PCL • Evaluate for Patellar Dislocation

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