Knee & HipExaminations

Family Medicine Academic DayMarie-Josée Klett, MD CCFP Dip Sport Med

Louise Walker, MD CCFP FCFP Dip Sport Med Department of Family Medicine

University of Ottawa

Confidentiality and Conflict Declaration

Speakers have no conflicts of interest to declare

This presentation and associated handouts are for use by University of Ottawa DFM residents and are not to be used for other purposes or distributed without the written consent from the speakers

Knee History

• Role play

Knee History

Nature of the problem – pain, swelling, catching/locking, giving way

DurationMechanism of injuryLocation of painRadiation of the painAggravating factorsRelieving factorsPain during and/or after activityRx to date; Past Hx; ROS; FHx; Meds; Allergies; “Other”-reason for visit at this time; sporting

history; legal

LOOK

Standing: Alignment

Knee: Normal, Recurvatum, Holds in Flexion Varus (finger distance between knees)

Valgus (intermalleolar distance)

Deformity Visible swelling front or popliteal spaceFeet: Pes planus, Pes cavus, Overpronation

Alignment

Feet

Overpronation

Baker’s cyst

LOOK

Walking:

Gait: Antalgic favours: Right or Left

Varus thrust

PWBNWB

AIDS: crutches/cane/w/c

LOOK

Sitting

Skin - Redness/Blueness/Mottled/Abrasions/Scar/Ecchymosis

Muscle – contract quads- Lateral Tracking (“J” Sign)

Tibia: Internal RotationExternal Rotation

FEEL

Palpate Point(s) of Maximal Tenderness:

Bones: joint lines (knee bent), femoral condyles (knee bent), patellar facets, tibial plateau/tubercle, fibula

Ligaments: MCL, LCL

Tendons: Patellar, Quad, Hamstring, ITB, Pes Anserine

Can also feel soft tissue swelling and muscle bulk (atrophy)

Surface Anatomy: Practice

Pes Anserine

MOVE

Range of Motion: Active, Passive, Resisted

Extension

Flexion

Feel for Crepitus (retropatellar during active flexion/extension)

Hip screen: at least passive Flex + IR + ER(Ext/Abd/Add if abnormal)

Special Tests

• Meniscus• Ligaments• Patella

Meniscus: Anatomy

Meniscus: History

• Usually specific incident: most often twisting injury

• Often associated with swelling, can have catching and/or locking

• Pain with squatting, kneeling, twisting• Medial or lateral pain but sometimes difficult

to localise

Meniscus: Physical Exam

• Often have small to medium effusion: bulge test• http://www.youtube.com/watch?

v=LsgutijmX7U• Pain with passive flexion OR 2.3• Joint line tenderness Sens 76% Spec 29%

Meniscus: Physical Exam

• McMurray: externally rotate and abduct for medial, internally rotate and adduct for lateral, click with pain is positive.(Sens 52% Spec 97%)

• Thessaly: twist on affected knee with 20o of flexion, pain is positive. (Sens 96% Spec 95%)

• Apley Grind: patient prone, apply load to knee and grind, pain is positive. (Very little data)

Meniscus: Thessaly

Practice

• Passive flexion and extension• Bulge test• McMurray’s• Thessaly’s

Ligaments: Anatomy

MCL: Anatomy

ACL: Anatomy

Ligaments: History

• Mechanism of injury:– Collaterals: valgus or varus force– ACL: plant and twist, hyperextension or quick

deceleration– PCL: direct anterior force on bent knee

(dashboard injury or fall onto tibia of flexed knee)• May have heard/felt a pop• ACL: immediate large swelling• Feeling of instability

MCL/LCL: Physical Exam• LOOK – soft-tissue swelling• FEEL - tenderness over ligament• TEST- at 0 and 20 degrees-test for pain and laxity to

differentiate grade of injury

PCL: Physical Exam

• Mild to moderate effusion• May not have any palpable

tenderness but can feel step-off• Posterior Sag/Posterior drawer

test

PCL: Posterior Sag

PCL: Posterior Drawer

ACL Physical Exam:

• Hemarthrosis: large effusion (patellar tap)

• May have associated meniscal or MCL tear

• Can have avulsion fracture lateral tibial plateau so tenderness there common

• Lachman (15-30o flexion) most sensitive and specific knee test, Anterior Drawer, Pivot Shift (if MCL intact and no meniscus tear)

Anterior drawer: Sens 48% Spec 87% Pivot shift: Sens 61% Spec 97% (but only studied by its

developers) Lachman’s: Sens 87% Spec 93%, LR+ 42.0

ACL: Lachman’s

Practice

• Lachman’s (or Drop Leg Lachman’s)• MCL & LCL Collateral tests (at 0 and 20)• Posterior Drawer

Patella: Anatomy

Patella: History

• Anterior knee pain• Often worse going down stairs, squatting,

kneeling• Sometimes pain will cause quads inhibition-

patients get giving way

Patella: Physical Exam

• Look for contributing biomechanical factors: genu valgus, femoral anteversion, pes planus/overpronation

• Tender patella facettes, retropatellar crepitus• J-sign• Assess patella: Laxity/apprehension,

compression/Osmond-Clark• Assess for correctable factors:

– Tightness: hamstrings, IT Band (Ober’s)– Strength: VMO, abductors

Patella: Obers

Practice

• Palpation of patellar facets• J-sign• Laxity/apprehension• Compression test• Ober’s• Hip Abductor strength

HIP ASSESSMENT

HISTORYChief Complaint:Mechanism of injury:Duration:Location: Lateral Anterior Other - “C” SIGNRadiation:Groin Buttocks Thigh OtherSeverity when most severe: (0 to 10)Catching:When does pain occur? (rest; sitting; walk; run; stairs up/down; uneven ground; in/out car; during activity; after activity; morning; afternoon; night; other relation to bowel bladder, menses):Relieving Factors:Treatment to date:Past history of knee injury or related hx:Other medical history:Medication:Allergies:

Hip: Location of Pain

HIP: PHYSICAL EXAMINATION

LOOK

FEEL

MOVE

SPECIAL TESTS

LOOK

Standing: Alignment

Walking: Antalgic favours: Right Left

Trendelenburg

PWB NWB

AIDS: crutches/cane/w/c

LOOK

Lying:

Swelling

Muscle wasting

Flexion deformity

Position

FEEL

Palpate points of maximal tenderness:

Bones: ASIS, Greater trochanter and bursa, Pubic ramus and symphysis, Ischial tuberosity, SI joints

Muscles & Tendons: Adductors, IT band (TFL), gluteus minimus/maximus, piriformis, Hamstring

Abdomen and Lumbar Spine if indicated

Hip bones

Hip Muscles

“Glutes” and GT Bursae

Piriformis

Glut Minimus

GT Bursa of Glut Medius

Glut Medius

GT Bursa of Glut Maximus

Glut Maximus

Practice

• Bones:– Greater trochanter– Pubic Symphysis– Anterior Inferior and Superior Iliac Spine– Ischial tuberosity– SI joints

• Muscles:– Piriformis

MOVE

Hip Range of Motion: Active Passive Resisted

Flexion: (~120°)Extension: (~20-30°)Abduction: (~45-50°)Adduction: (~20°)Internal rotation: (~35°)External rotation: (~45°)

Special Tests

FAI or FADDIR testing: labrum/joint

Trendelenburg test: abductor strength

Thomas test (flexion contracture/ITB tightness)

FABER: Pain (groin, lateral, SI)

Functional tests: Hop on Rt and Lt (pain?)

Flexion-adduction-internal rotation test (FAI)

Trendelenburg test

Thomas test

FABER

Back: Special Tests

• Back ROM:

Flexion Extension Lateral flexion Rotation

• Sacro-iliac Kinetic Test

• Leg Lengths: Rt_____cm. Lt_____cm.

Practice

Passive IR

FAI test

Trendelenburg test

Thomas test

FABER

Thank You!