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1. EXAMINATION OF KNEE مقاربة سنة سادسة Dr Haitham Al Ahmar

2. Examination of the knee Introduction Anatomy History taking Routine knee joint examination Special tests

3. Anatomy Largest and most complex synovial joint. Three articulation Medial tibio -femoral Lateral tibio -femoral Patello -femoral

4. Broadly classified in to following Osseous Structures. Extra- articular Tendinous Structures. Extra- articular Ligamentous structures Intra- articular soft tissue elements .

5. Osseous structures

6. Patella Triangular sesamoid bone.

7. Extra- articular tendinous structure Comprises of quadriceps, medial and lateral hamstrings, popliteus , gastrocnemius and iliotibial band.

8. Poplitius muscle has 3 origins intracapsularly . A.Lateral femoral condyle . B.Posterior horn of the lateral meniscus. C.Fibula . Femoral and tibial origins form the arms of an oblique Y shaped ligament.

9. Semimembranosus muscle has 5 distal expansion. 1.The oblique popliteal ligament. 2.A second tendinous attachment. 3.Anterior or deep head. 4.The direct head and 5.The distal portion of the semimembranosus .

10. Extra- Articular Ligamentous Structures Capsule extends from patella and patellar tendon anteriorly to medial lateral and posterior recess of knee. Medial side it blends with tibial colateral ligament and attached to medial meniscus. Laterally all are separate entity.

11. Medial capsule is divided into 3 regions. Antero-medial portion reinforced by medial patellar retinacula . Mid-medial capsule is the deep layer of the MCL. Postero -medial capsular region or the Posterior oblique ligament . Extends from posterior edge of MCL to the insertion of the direct head of semimembranosus .

12. Medial collateral ligament Superficial MCL or tibial collateral ligament . Deep MCL . ORIGIN Medial epicondyle . INSERTION 7-10cm below joint line. Deep to pes anserinus .

13. Medial aspect of the knee is divided into 3 layers. 1 st layer-Deep fascia containing the sartorius fascia. 2 nd Layer-Superficial MCL or Tibial collateral ligament. 3 rd Layer-Deep MCL which blends with the joint capsule.

14. Lateral collateral ligament ORIGIN Latera epicondyle of femur. INSERTION Head of fibula. Neither fuses with the capsular ligament or the lateral meniscus. More suceptible to injury.

15. Lateral aspect of the knee is divided into 3 distinct layers. 1 st layer-contains Iliotibial tract and superficial portion of the biceps tendon and common peroneal nerve. 2 nd layer-lateral collateral ligament. 3 rd layer-Lateral part of the joint capsule.

16. Intra- Articular Structures synovial membrane Attached to margins of the articular surfaces and to the superior and inferior outer margins of the menisci. Bursae Suprapatellar bursa, Prepatellar bursa, Infrapatellar bursa.

17. Anterior cruciate ligament Intra- artricular extra synovial structure. Primary restrain to anterior tibial translation. Inner surface of lateral condyle of femur to inter condylar eminence of tibia. Two band- anteromedial and postero lateral.

18. Posterior cruciate ligament Also intracapsular and extrasynovial structure. Originates from the junction of the femoral notch roof and medial femoral condyle . Roughly 1 cm proximal to the articular surface. Inserts on the posterior aspect of the proximal tibia at the fovea. Two bands- anterolateral and posteromedial .

19. Medial meniscus. C shaped structure . Larger than lateral meniscus. Anterior horn attached to tibial surface anterior to the tibial eminence and the ACL. Posterior horn is attached just in front of the attachment of the PCL. Not attach to either of the cruciate ligaments, but attaches to the medial capsular ligaments.

20. Lateral meniscus More circular than medial meniscus. Covers up to 2/3 rd of articular surface of tibia. Anterior horn attached in front of the intercondylar tibial eminence and posterior horn- in front of the posterior attachment of the medial meniscus. Ligament of humpry - ant. menisco femoral lig . Ligament of wrisberg - post. Meniscofemoral ligament.

21. CHIEF COMPLAINS Pain Swelling Stiffness Mechanical Disorders (locking, giving Way, click) Limp Deformity

22. Mechanism PCL Backward thrust on a flexed knee Dashboard injuries ACL Audible "pop" Rapid knee swelling Rapid deceleration with knee in rotation and valgus stress.

23. Historical clues Noncontact injury with “pop” ACL tear Contact injury with “pop” MCL or LCL tear, meniscus tear, fracture Acute swelling ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation Lateral blow to the knee MCL tear Medial blow to the knee LCL tear Knee “gave out” or “buckled” ACL tear, patellar dislocation Fall onto a flexed knee PCL tear

24. Common problem in relation to age

25. Symptoms 1. Pain Site Onset n duration Character Pain at night - inflammatory cause Pain - mechanical in origin. towards evening during/after exercise

26. Pain - indicative of patellar problems Going up or down stairs Aching in positions where the knee is kept flexed for prolonged periods of time. Bar- or vice-like pain below the patella

27. 2. Swelling Causes Infective Traumatic Degenerative Inflammatory tumor

28. 3. Laxity "Going out" torn ACL or a dislocation of the patella. "Giving way" sensation of the knee suddenly failing to provide proper support especially when walking on uneven ground.

29. 4.Locking It is the inability to fully extend the knee for an appreciable period of time. Causes : bucket-handle tear of the meniscus bulky flap that has dislocated forwards in the joint a loose body or an ACL stump

30. EXAMINATION Expose both lower limbs from groin to toes. Postions Standing Seated position Supine position Lastly prone position Always examine the hip joint and opposite knee joint. Gait . Attitude.

31. Inspection done while the patient is standing Alignment Genu Valgus (knock-knee) ( Intermaleolar distance ›9cm) Genu Varus (bow leg) ( intercondylar distance › 6cm) Flexion deformity Genu recurvatum Shortening Baker’s cyst Gait

32. Inspection done in supine Masses Bursae : Housemaid’s ( prepatellar bursitis), clergyman’s ( infrapatellar bursitis). Bony : Exostosis Tumor of femur / tibia Scars Signs of trauma previous surgery

33. Swelling – localised or diffuse Redness Muscle bulk and symmetry Displacement of the patella

34. Palpation / Feel Temperature change Tenderness: joint line tenderness -done by flexing the knee and palpating the joint line with the thumb. Tederness of tibial tubercle / patellar tendon /quadriceps tendon.

35. Bony palpation Knee in 90 deg flexion Medial aspect

36. Lateral aspect

37. Effusion Patellofemoral crepitus Thickened synovial membrane- spongy/boggy feel, edge can be rolled. Quadriceps and hamstrings power. Popliteal and inguinal lymph node.

38. Effusion: Fullness of parapatellar fossae . Bulge sign : useful for smaller effusions. Squeeze the suprapatellar pouch. Stroke the medial side of joint to displace it laterally. Stroke the lateral side & see for the filling of medial side.

39. Patellar tap: T est for identify moderate effusion . press suprapatellar pouch with one hand. with the index and middle finger of other hand push the patela towards femoral condyle with a jerk. patella is felt to strike the femur then bounce back.

40. Coss fluctuation test For moderate to severe effusion. With thumb on one side and fingers on other side, compress the the knee to empty the hollows. Now with the other hand forcefully compress the fluid to knee joint. Findings- fluid impulse is transmitted across the joint.

41. In prone Popliteal fossa Semimembranosus bursa Bakers cyst

42. MOVE Movement: . ACTIVE & PASSIVE Flexion –Extension: Normal 0-135 degrees. Rotation: 20-30 deg in flexion, Nil in extension. Fixed flexion deformity : by passively lifting the leg at the heel to see if there is complete extension .

43. See for crepitus during motion . See hip rotations, as pain can be referred from the hip. Repeat each movement for the opposite leg at the same time.

44. Measurements Thigh circumference Mark joint line. 18 cm above(maximum bulk). Compare with normal knee. ›2cm difference is significance. Calf circumference . Limb length.

45. TESTS FOR MENISCAL INJURY Joint line tenderness: medial joint line tenderness- medial meniscus tear. lateral joint line tenderness- lateral meniscus tear .

46. McMurray test: knee acutely flexed palpate medial joint line + external rotation + gradual extension -click/pain s/o medial meniscus tear. palpate lateral joint line + internal rotation + gradual knee extension -click/pain . s/o-lateral meniscus tear. Negative McMurray test doesn’t rule out tear.

47. Apley Grinding test: prone position; knee 90 degree flexion; compression and rotation than look for pain

48. Thessaly test Patient stands flat footed on one leg. Examiner hold his/her hand. Knee flexed to 20°. Ask pt to twist body side to side three times. Pain at medial or lateral joint line, locking- meniscal tear

49. TEST FOR ACL INJURY: Anterior drawer test Supin Hip – 45° Knee – 90° Foot flat on table and stabilized Apply force so to pull and look for subluxation Ensure tibia is not sagging behind-otherwise false positive result Not possible in acute painful knee

50. Lachman test Knee flexed at 30° Hamstrings relaxed Femur stabilised. Anterior pull of tibial condyle . Amount of anterior translation and the feel of endpoint(soft/mushy/firm) compared to the opposite knee. Grades Gr 0 : negative Gr 1+ : 0- 5mm with firm end pt Gr 2+ : 5-10mm, soft end pt Gr 3+ : 10 mm,soft end pt

51. Pivot Shift Test Pt supine, relaxed Knee in IR and valgus strain ( subluxates the knee) Do gradual flexion from extension. See for the reduction of the lateral femoral condyle at around 30° of flexion. Most specific for ACL tear.

52. TEST FOR PCL INJURY Sag sign Knee 90 Support heel Tibia sags visibly posteriorly from effect of gravity Compare silhouette both side Godfrey sign : sag sign at 90 flexion at hip & knee

53. Posterior drawer test Supine Knee 90 deg Excessive posterior laxity / no hard end point felt s/o PCL tear

54. Quadriceps Active Test Supine Knee 90 deg Active gentle quadriceps contraction to shift tibia without extending knee Anterior shift of tibia-PCL tear

55. TEST FOR MCL INJURY Valgus stress test Supine Side Of Table Abducted Of The Side Of table In full extension and Flexion 30 degree. Valgus Strain Observe Stability. Hugston et al- positive at 30° flexion negative at 0°- only MCL tear + ve at Extension- tear of both MCL and PCL.

56. TEST FOR LCL INJURY Varus stress test Varus Strain Given Similarly at 30 deg flexion. Observe Instability. Marshall et al- positive only in flexion indicates tear of the LCL. positive in full extension -combined injury to the LCL,popliteus and cruciate ligaments.

57. POSTEROLATERAL CORNER INJURY (PLC) External Rotation Recurvatum test Dial test: External rotation of tibia is compared at 30 & 90 flexion; > 10 deg increased -+ ve . Reverse Pivot Shift Test

58. Dial test Check for external rotation of foot (thigh foot angle). At 30° and 90° knee flexion. Increased rotation at 30° that decreases at 90° - PLC injury Increased rotation at both 30° and 90° - both PLC and PCL injury. › 10° difference is pathognomic .

59. Posterolateral drawer test Knee flexed at 90 degree and foot in external rotation. Apply backward pressure on tibia. Excessive travel on lateral side indicative of posterolateral instability.

60. External rotation recurvatum test Patient in supine position. Stand at the end and lift both legs holding the great toes. Test is positive if the knee falls into external rotation, varus and recurvatum .

61. jakob’s reverse pivot shift test Flxed the knee to 90 degree. Externl rotate the foot. Apply valgus stress and extend the knee. If test positive then the posteriorly subluxed knee reduced at 20 degree extension.

62. Anterolateral rotatory instability Slocum’s Anterior Rotatory Drawer Test Modification of anterior drawer test. Pt supine, knee flexed to 90°. Knee in 15° internal rotation. Perform anterior drawer test. Anterior subluxation of lateral tibial condyle - + ve . Reduces with knee in external rotation.

63. Jerk test of Hughston and Losee patient in supine , knee is flexed to 90 deg with the tibia in internal rotation. knee gradually extended with valgus stress applied. Test is positive if the lateral tibia subluxes anteriorly in the form of sudden jerk at about 30 deg of flexion.

64. Antero medial rotatory instability Slocum’s Anterior Rotatory Drawer Test Pt supine, knee flexed at 90°. Tibia in 30° external rotation. Perform anterior drawer test. Excessive excursion of the medial tibial condyle suggests positive test.

65. PosteroMedial Rotatory Instability Hughston’s Posteromedial drawer test . Patient in supine position and the knee flexed to 90 °. Foot in internal rotation. Apply backward pressure on the tibia. Excessive excursion of the medial tibial condyle suggests positive test.

66. PATELLA Position Palpating the borders Tenderness Mobility Tracking Q angle Tests Apprehension Grind test

67. position Both knee flexed at edge. Show torsional deformity of femur or tibia or laterally placed patella.

68. tenderness Over anterior surface or presence of bipartite ridge. Lower pole tenderness ( sinding larsen johannnson syndrome). Displace medially and palpate the articular surface ( chondromalacia patella). Repeat the test displacing laterally.

69. Q angle Angle between a line from ASIS to centre of patella and centre of patella to tibial tuberosity . N-♂8-10°♀15±5° Greater the Q angle, the greater the tendency to move the patella laterally against the lateral femoral condyle .

70. PATELLAR TESTS Apprehension test Supine Knee 10-30deg flexion push the patella in a lateral direction Patient stops the examiner

71. Patellar tracking Knee at 90 deg to full extension Shifts laterally at terminal extension Excess lateral shift /tilt terminally indicates patellar instability Figure 6-66. Assessing patellar tracking.

72. THANK U