The Lower Limb
•
Sarah Rayner
•
Ove Indergaard
•
Tim Hughes
•
Mark Williams
Learning Objectives
Please list
Aim
•
To improve your knowledge and skills related to knee
problems
Objectives
By the end of today you will be able to:
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Take a relevant history
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Be able to examine the knee with confidence
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Make a provisional diagnosis
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Institute a management plan
The Knee
MSK VTS 8th January 2014
Ove Indergaard MSc MCSP HCPC
Chartered Physiotherapist
Specialist Sports Physiotherapist
The Subjective Examination
Anatomy
Anatomy
Not always this obvious!
• Subjective History
We are trying to determine what structures have been damaged
and to what extent?
Important things to include:
1.Mechanism of Injury
• Acute or Overuse (Sudden or gradual onset)
• Primary mechanisms are:
– Valgus force (with or without rotation)
• MCL
• O’Donohue’s Triad of MCL/Med Meniscus/ACL
– Hyperextension
• ACL
• PCL
Subjective History
– Flexion with rotation and posterior translation
• PCL
– Varus Force
• LCL
• Posterolateral Capsule
• Subjective History
Important things to include:
•
Was the Knee in an open (OC) or closed Chain (CC)?
–
Patella subluxations caused by rotation of the tibia on the femur in
CC.
–
meniscal injuries occur when the knee is weightbearing (CC) and
rotated.
2. Amount of pain and disability at the time of injury
–
How severe was it?, did they have to stop competing? Could they
walk off the pitch or did they need help?
3. The presence and timing of onset of swelling.
–
Quick onset (>2h) usually haemarthrosis caused by ACL/PCL
rupture or Patellar dislocation
–
Delayed onset (6-24h) Effusion, more likely with meniscal injuries
–
No Swelling, likely to be more superficial structures(MCL/LCL)
Subjective History
4. The degree of pain and disability at the point of examination
–
What are they like now? Have things improved? How long did it
take to settle?
–
Quality of pain
5. Other things to bear in mind when doing the history:
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Previous history of injuries
–
Any “Clicking” currently?, was there a “pop” at the time of the
injury? (may indicate an ACL tear or osteochondral fracture.)
–
Instablity (episodes of true giving way, or just feeling of)
History
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Mechanism of injury
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Acute or overuse
•
Open or closed chain
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Severity of pain and disability at injury
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Swelling? Timing?
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What are things like now
•
Quality of pain
History
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Previous injury
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Clicking?
•
Pop at injury?
•
Instability?
Causes of knee pain
Ligament injuries
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ACL
•
PCL
•
MCL
•
LCL
•
Grading I II III (<25%, <75%, >75%)
Anterior Cruciate Ligament
Anterior Cruciate Ligament
Anterior Cruciate Ligament
Anterior Cruciate Ligament
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History of trauma
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Aftermath from trauma
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Effusion?
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Function?
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Time to resolution
•
Locking? Giving way?
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Conservative or surgical?
Posterior Cruciate Ligament
Posterior Cruciate Ligament
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Rotation
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Hyperextension
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Hyperflexion
•
Dashboard or similar
•
Similar story to ACL
•
Less likely to need surgery (giving way?)
O’Donoghue’s Unhappy
Triad
•
ACL
•
MCL
•
Medial Meniscal Tear – more likely to be lateral
meniscus
Associated Injuries
•
100 consecutive patients with ACL tear
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53 medial collateral ligament injuries,
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12 medial, 35 lateral and 11 bicompartmental
meniscal lesions.
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59/100 contact sports,
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30/100 downhill skiing
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11/100 in other recreational activities, traffic accidents
or at work
Medial Meniscal Injury
Meniscal injuries
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Rotational forces
•
Locking?
•
Giving way (muscle wasting)
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Avascular and aneural and usually painless
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Tender joint line? Effusion and wasting
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Special tests
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Treatment conservative or
•
surgical (osteoarticular transplantation (OATS))
2006 World Cup
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http://www.youtube.com/watch?v=oHgu5e9K3Ww
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Which Knee is affected?
Tendonopathy
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Patella or Quadriceps
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(hamstring, popliteus, pes anerinus)
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Morning stiffness
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Reduced function
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Localised swelling and tenderness
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Eccentrics / nitrate patch / shockwave? / PRP?
Iliotibial Band Syndrome
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Aching over lateral aspect of knee
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Tenderness
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Tight ITB and Glut Maximus
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Compressive problem
•
•
Caused by poor muscles, biomechanics or
inappropriate training
Stretching and strengthening
Bursitis
Bursitis
Bursitis
Patellofemoral pain
syndrome
Patellofemoral pain
syndrome
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Around patella, deep, posterior, often lateral
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Poor localisation
•
Eccentric loading most painful
•
Causes?
•
•
•
•
•
•
•
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Quadriceps Weakness and shortness
Misfiring between VMO and VL, delayed contraction
Hip Abductor dysfunction (Increased Q angle)
Femoral Anteversion
Increased Levels of Activity
Leg Length Discrepencies
Depressive Passive Attitude
Hypermobile Patella
•
Osgood Schlatter
Syndrome
10-12 in girls / 13-15 in boys
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Traction apophysitis
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Activity and growth
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(Sinding-Larsen Johansson)
Osteoarthritis
•
•
•
•
•
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Morning stiffness
Night pain
Swelling
Loss of function
Some ease with activity
Management
Other causes
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Mono/poly arthritis
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Seroneg arthropathy e.g. AS, psoriasis, Reiter’s
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Gout
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Septic
•
Joint hypermobility syndrome
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Referred from back or hip
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Need to mention Baker’s cyst
Surface Anatomy
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Why?
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http://www.youtube.com/watch?v=_q-Jxj5sT0g
The Objective Examination
Surface Anatomy
Practical Palpation Skills:
Identify, feel and and mark the following;
•Patella (mark the Apex)
•Condyles
•Joint line (draw the joint line)
•MCL and LCL (draw the MCL)
•Patella tendon
•Fat Pad
•ITB (Gerdy’s Tubercle)
•Pes Anserinus
Examination
• Observation
– Standing, Walking, Functional movement, Supine
• Active movement
– Flexion
– Extension
• Passive Movement
– Flexion
– Extension
– Internal and External Tibial Rotation
• Palpation
- Effusion Test
Special Tests
•Ligaments
– MCL
– LCL
– ACL
– Lachmans (Acute: sensitivity .77 , specificity >.95 , Chronic: sensitivity .85
and specificity >.95)
– Anterior drawer (sensitivity,.18-.92 and specificity .78-.98)
– PCL
– Posterior sag test
– Posterior drawer (sensitivity .90 specificity .99)
Special Tests
–
Meniscal Tests:
– McMurrays (specificity 70%, sensitivity 71%)
– Thessalys
– Thessaly Test at 5° -Injury to Medial Meniscus:
Sensitivity = 0.66, Specificity = 96%, Injury to Lateral
Meniscus: Sensitivity = 0.81, Specificity = 0.91,Combined
Injury of ACL and Meniscus: Sensitivity = 0.65, Specificity
= 0.83
– Thessaly Test at 20° Injury to Medial Meniscus:
Sensitivity = 0.89, Specificity = 0.97,Injury to Lateral
Meniscus: Sensitivity = 0.92, Specificity = 0.96, Combined
Injury of ACL and Meniscus: Sensitivity = 0.80, Specificity
= 0.91
– Patellofemoral joint
– Patella Apprehension Test
•
Resisted Tests
– Quads
– Hamstrings
• Functional Tests
– Squat
– Single knee bend
– Sports specific movements
Case Studies
1.
Stephanie is a 25 year old office worker. She
presents with pain around and below her right
knee and a locking sensation which occurred last
evening at a step aerobics class. She had to
leave the class as a result of the pain and this
morning she feels the knee has swollen. Her
records disclose a note concerning a previous
episode when she attended the A&E department:
Painful effusion R knee after aerobics, XR
normal, FBC, viscosity, urate normal Rx; rest,
tubigrip, naproxen.
Case Study
2.
Michael is a 45 year old teacher who has take up running
again after a few years off. He presents to you complaining
of pain at the apex of the left patella which feels sore when
first starting running, then eases off after 5-10 minutes. He
also feels a lot of pain and stiffness in the morning after he
has run. But generally he has stiffness and slight soreness
after long periods of staying seated. The knee then aches
for a couple of steps before the pain goes away again.
Case Studies
3. Jemima is a tall, slim, 14 year old girl who is very keen on ballet
and gymnastics. She is complaining of bilateral knee pains
which seem to be aggravated by her activities.