Musculoskeletal
Curriculum
History &
Physical Exam of
the Injured Knee
Copyright 2005
Authors
Kathleen Carr, MD
Madison Residency Program
Kathleen.Carr@fammed.wisc.edu
Dennis Breen, MD
Eau Claire Residency Program
Dennis.Breen@fammed.wisc.edu
Dan Smith, DO
2
Contributors
Marguerite Elliott, DO
Jeff Patterson, DO
Jerry Ryan, MD
3
Goal

Learn a standardized, evidence-based history
and physical examination of patients with knee
injuries
WHICH WILL:

Enable family medicine resident physicians to
accurately diagnose common knee problems
throughout the full age spectrum of patients
seen in family medicine
4
Competency-Based Objectives

Patient care – focused history and exam

Professionalism – respect, compassion

Interpersonal and communication skills –
differential diagnosis

Medical knowledge base – anatomy, injury
mechanisms

Systems based practice – accuracy, time-efficiency
5
Assessing a knee injury

Components of the assessment include



Focused history
Attentive physical examination
Thoughtfully ordered tests/studies

for future discussion
6
Focused History
Focused History Questions

Onset of Pain


Date of injury or when symptoms started
Location of pain*




Anterior
Medial
Lateral
Posterior
8
Focused History Questions

2
Mechanism of Injury -helps
predict injured structure

Contact or noncontact injury?*


If contact, what part of the knee was
contacted?

Anterior blow?

Valgus force?

Varus force?
Was foot of affected knee planted
on the ground?**
Valgus alignment =
distal segment
deviates lateral with
respect to proximal
segment.
Patellas Touch
http://moon.ouhsc.edu/dthompso/namics/varus.gif
9
Focused History Questions

3
Injury-Associated Events*

Pop heard or felt?

Swelling after injury (immediate vs delayed)

Catching / Locking

Buckling / Instability (“giving way”)
10
Instability - Example
Patellar dislocation
http://www.carletonsportsmed.com/Libraria_medicus/PF_patella_dislocat
ion.JPG
11
Focused History Questions
 Degree
4
of Immediate Dysfunction
|------------------------|
Unable to
Ambulate
Antalgic
Gait*
Continued
to Participate
12
Focused History Questions

Aggravating Factors


Activities, changing positions, stairs, kneeling
Relieving Factors/treatments tried


5
Ice, medications, crutches
History of previous knee injury or surgery
13
Historical Clues to Knee Injury
Diagnoses
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
14
Physical Exam
Physical Exam - General


Develop a standard routine*
Alleviate the patient's fears
GENERAL STEPS
Inspection
Palpation
Range of motion
Strength testing
Special tests
16
Physical Exam - Exposure



Adequate exposure - groin to
toes bilaterally
Examine in supine position
Compare knees
17
Observe – Static Alignment
Patient stands facing examiner with
feet shoulder width apart



Ankles, subtalar joints – pronation, supination
Feet – pes planus, pes cavus
Pes planus
(http://www.steenwyk.com/pronsup.htm)
Pes cavus
(http://www.arc.org.uk/about_arth/booklets/6012/images/6012_1.gif)
18
Observe – Static Alignment

Patient then
brings medial
aspects of knees
and ankles in
contact

Knees – genu valgum
(I), genu varum (II)
Genu valgum
Genu varum
(http://www.orthoseek.com/articles/img/bowl1.gif)
19
Observe – Dynamic Alignment

Pronation/Supination may be
enhanced with ambulation

Antalgic gait indicates significant
problem (anti = against, algic = pain)
20
Inspect Knee
 Evidence
of
local trauma
Abrasions
 Contusions
 Lacerations




Warmth
Erythema
Effusion*
 Patella
position
 Muscle atrophy
21
Inspect Knee-Related Muscles
Quadriceps atrophy


Long-standing problem
Vastus medialis
atrophy


After surgery
http://www.neuro.wustl.edu/neuromuscular/pics/people/patients/Hands/ibmquadatrsm.jpg
22
Normal Knee – Anterior, Extended
23
Surface Anatomy - Anterior, Extended*
Patella
Indented
Hollow
24
Normal Knee – Anterior, Flexed
25
Surface Anatomy - Anterior, Flexed
Patella
Tibial
Tuberosity
Head
Of
Fibula
26
Palpation – Anterior*
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar Facets
Medial Fat
Pat
Lateral Fat Pad
Patellar Tendon**
27
Surface Anatomy - Medial
Tibial
Tuberosity
Joint
Line
Patella
Medial
Femoral
Condyle
Medial
Tibial
Condyle
28
Palpation - Medial
Medial Collateral Ligament (MCL)*
Pes anserine
bursa**
Medial joint
line
29
Surface Anatomy – Lateral
Quadriceps
Patella
Tibial
Tuberosity
Head
Of
Fibula
30
Palpation – Lateral*
Lateral Collateral
Ligament (LCL)**
Lateral joint
line
31
Palpation - Posterior

Popliteal fossa*

Abnormal bulges



Popliteal artery aneurysm
Popliteal thrombophlebitis
Baker’s cyst
32
Range Of Motion Testing

Extension
0º

Describe loss of degrees of extension


Flexion
135º
Example: “lacks 5 degrees of
extension”
Locking* = patient unable to fully extend or flex
knee due to a mechanical blockage in the knee
(i.e., loose body, bucket-handle meniscus tear)
33
Strength Testing

Test knee extensors (quadriceps) and knee
flexors (hamstrings)




Can test both with patient in seated position,
knees bent over edge of table
Ask patient to extend/straighten knee against your
resistance
Then ask patient to flex/bend knee against your
resistance
Compare to unaffected knee
34
Special Tests – Anterior Knee Pain

Patellar apprehension test*
Starting
position
Push patella
laterally
(http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/lateral%20patellar%20
apprehension.htm)

Patellofemoral grind test**
35
Special Tests - Ligaments
Anterior Cruciate

Posterior
Cruciate
Assess stability
of 4 knee
ligaments via
applied
stresses*
Medial Collateral
Lateral Collateral
36
Stress Testing of Ligaments
Use a standard exam routine




1.
Direct, gentle pressure
No sudden forces
Abnormal test
Excessive motion = laxity
What is NORMAL motion?*
2.
Soft/mushy end point**
37
Collateral Ligament Assessment
Patient and Examiner
Position*
38
Valgus Stress Test for MCL*
Note Direction Of Forces
39
Video of Valgus Stress Test
Click on
image for video
40
Varus Stress Test for LCL*
Note direction of forces
41
Video of Varus Stress Test
Click on
image for video
42
Lachman Test*


Patient Position
Physician hand placement
43
Lachman Test2

View from lateral aspect*
Note direction of forces
44
Video of Lachman Test
Click on
image for video
45
Alternate Lachman Test
Click on
image for video
46
Anterior Drawer Test for ACL


Physician Position & Movements*
Patient Position
Note direction of forces
47
Posterior Drawer Testing- PCL*
Note direction of forces
48
Assess Meniscus – Knee Flexion

Most sensitive test is full flexion*


Examiner passively flexes the knee or has patient
perform a full two-legged squat to test for
meniscal injury
Joint line tenderness**

Flexion of the knee enhances palpation of the
anterior half of each meniscus
49
Tests that we do not
recommend routinely

Pivot-Shift* - for ACL tear

McMurray Test**- for meniscus tears
50
Review of Evidence – ACL*
(Jackson JL, et al.)



Lachman Test
Anterior Drawer
Pivot Shift Test
Sens 87% Spec 93%
Sens 48% Spec 87%
Sens 61% Spec 97%
51
Review of Evidence - Meniscus
(Jackson JL, et al.)


Joint Line Tenderness
McMurray Test
Sens 76% Spec 29%
Sens 52% Spec 97%
52
References
Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part I.
History, Physical Examination, Radiographs, and Laboratory Tests. Am Fam
Physician 2003;68:907-12.
Ebell MH. A Tool for Evaluating Patients with Knee Injury. Family Practice Management.
March 2005:67-70.
Jackson JL, O’Malley PG, Kroenke K. Evaluation of Acute Knee Pain in Primary Care.
Ann Intern Med. 2003;139:575-588.
Malanga GA, Andrus S, Nadler SF, McLean J. Physical Examination of the Knee: A
Review of the Original Test Description and Scientific Validity of Common Orthopedic
Tests. Arch Phys Med Rehabil 2003;84:592-603.
Solomon DH, Simel DL, Bates DW, Katz JN. Does this patient have a torn meniscus or
ligament of the knee? Value of the Physical Examination. JAMA 2001;286:16101620.
53
Video of Knee Exam
http://www.fammed.wisc.edu/our-department/media/musculoskeletal
54