DPT691 - 02 - Knee Examination (3).pdf

Examination Knee JUSTIN TRENT UNIVERSITY OF SAINT MARY HOW DO WE CONDUCT AN EXAMINATION OF SOMEONE WITH KNEE DYSFUNCTION? The Path Ahead 1 Surface Anatomy 2 History 3 Observation and Screening 4 Foundational Tests and Measures 4 Special Tests and Measures Part One: Surface Anatomy Anterior Anatomy S...

Examination Knee JUSTIN TRENT UNIVERSITY OF SAINT MARY HOW DO WE CONDUCT AN EXAMINATION OF SOMEONE WITH KNEE DYSFUNCTION? The Path Ahead 1 Surface Anatomy 2 History 3 Observation and Screening 4 Foundational Tests and Measures 4 Special Tests and Measures Part One: Surface Anatomy Anterior Anatomy SURFACE ANATOMY A) Patella Prominent Bony Region in Anterior Knee B) Patellar Ligament 1’’ Wide Band-like Structure Inferior from Patella C) Tibial Tuberosity Distal Attachment of the Patellar Ligament D) Medial and Lateral Patello-Tibial/Meniscal Ligament Diagonal Cord in the Anterior Joint Space E) Medial and Lateral Meniscus Soft Structures in Anterior Medial/Lateral Joint Space E A D D B C E Medial Anatomy SURFACE ANATOMY A) Medial Femoral Condyle Bony Prominence Medial to the Patella B) Adductor Tubercle Distal Bony Prominence at Distal Adductors C) Medial Collateral Ligament Firm Structure that Pushes You Out of Medial Joint Space D) Pes Anserinus Proximal, Medial Slope of the Tibia A C D B Lateral Anatomy SURFACE ANATOMY A) Lateral Femoral Condyle Bony Prominence Lateral to the Patella B) Lateral Collateral Ligament Firm Structure that Pushes You Out of the Lateral Joint Space C) Fibular Head Distal and Posterior to the Lateral Femoral Condyle D) Gerdy’s Tubercle A Prominent Bump Halfway Between Tibial Tuberosity and Fibular Head D B C HOW DO WE LOCATE AND PALPATE THESE STRUCTURES? Part Two: History Examination History Who? What? Systems Review Tests & Measures When? Where? Overview HISTORY GOALS FORM A SUBJECTIVE HYPOTHESIS THOROUGH, YET CONCISE BUILD PATIENT RAPPORT GUIDELINES BE CONFIDENT BE COMPASSIONATE USE ACTIVE LISTENING PACE… PACE… LEAD WATCH FOR NON-VERBAL CUES Review of Systems & Red Flags WHO? General Health: Metabolic: Lifestyle: Malaise Night Pain Dizziness Chills/Sweats/Fever Unexplained Weight Loss/Gain Cardiopulmonary: Auscultation & Vital Signs* Lightheadedness Leg Cramping Coughing Integumentary: Skin or Trophic Changes* Swelling/Warmth* Drainage* Diabetes Metabolic Syndrome Sleep | Diet | Activity Smoking Medications (Types): Anti-inflammatory Nerve/Muscle Cholesterol Psych Red Flags: Prior History of Cancer Unexplained Fever Patient-reported Outcome Measures “No instrument is currently universally applicable across the spectrum of knee disorders” Use a combination of: Diagnostic Specific Outcome Measures International Knee Documentation Committee (IKDC) ACL Knee-Injury and Osteoarthritis Outcome Score (KOOS) Osteoarthritis Activity Measures Knee Outcome Survey Lower Extremity Function Scale Physical Performance Measures ROM & MMT Patient Profile WHO? Age Younger Population < 40 Years Tears (ACL/Meniscus/Osgood-Schlatter) Older Population > 40 Years Degenerative (OA) Chief Complaint Pain | Stiffness | Weakness | Giving-way Mechanism of Injury Level of Activity Past/Present Current Mobility Status/Willingness to Change History of Acute or Repetitive Trauma Work Status Walking/Lifting Demands Environment Habitual Positions/Activities Stairs Participation/Goals Recurrence Motivating Factors What Defines a Successful Outcome Lumbar History Language/Cultural Barriers Insidious | Repetitive | Trauma | Post-Surgical SINSS WHAT? Severity Mild | Moderate | Severe Irritability Mild | Moderate | Severe Nature Nociceptive | Neuropathic | Psychosocial Stage Acute | Recurrent | Chronic Stability Improving | Not-changing | Worsening Aggravating and Easing Factors WHEN? Nothing Happens Without Cause! Aggravating Factors Time of Day Specific Activity or Position Amount of Activity – Kennedy Stages Delay in Symptom Repercussions Nociceptive = None Inflammation = up to Hours Neuropathic = up to Days (2) Easing Factors Positions/Motions of Comfort Ice/Heat Medications (Kind and Strength) Kennedy Stages 1) Pain After 2) Pain Before and After 3) Pain Before, During, and After (Performance Unaffected) 4) Pain Before, During, and After (Performance Affected) Reduction 0-25% 25-50% 50-75% 75-100% Pain Pattern Takeaways WHERE? You can’t diagnose on pain patterns alone, but… Pain patterns can still be a useful tool BETTER THAN THE HIP… NOT AS GOOD AS THE FOOT AND ANKLE. PAIN TENDS TO STAY IN ZONES. (IE. ANTERIOR STRUCTURES CAUSE ANTERIOR PAIN) Part Three: Observation and Screening Observation INSPECTION & SCREENING Start Observing in the Waiting Room! Frontal View Weight-bearing Genu Varus/Valgus (Q-Angle) Skin Appearance (Sheen | Ecchymosis) Redness/Swelling/Discharge Quadriceps Atrophy Side View Genu Recurvatum Knee Flexion Contracture Posterior Swelling/Baker’s Cyst Knee Fracture SCREENING Step 1 Step 2 Ottawa Knee Rules Was there a Trauma? Age 55 Years or Older Tenderness at Head of Fibula Tenderness of Patella Inability to Flex to 90° Inability to Ambulate 4 Steps Pittsburgh Knee Rules Was there a Trauma? Age 50 Inability to Ambulate 4 Steps PRACTICE Observation of your Patient Review the Ottawa Rule Review the Pittsburgh Rule Part Four: Foundational Tests and Measures Overview OBJECTIVE EXAMINATION GOALS CONFIRM YOUR SUBJECTIVE HYPOTHESIS DETERMINE MOVEMENT CAPABILITIES QUANTITY, QUALITY, WILLINGNESS NARROW/PRIORITIZE TREATMENT OPTIONS GUIDELINES BE CONFIDENT EXPLAIN PROCEDURES WELL WATCH FOR NON-VERBAL CUES DON’T PUSH INTO AGGRAVATING POSITIONS TOO EARLY APPROPRIATELY EXPOSE AREAS FOR OBSERVATION Knee Range of Motion FOUNDATIONAL TESTING Look for Quantity, Quality, Willingness, and Provocation Active then Overpressure Extension (0°) Flexion (135°) Knee Manual Muscle Testing FOUNDATIONAL TESTING Look for Strength, Quality, Willingness, and Provocation Extension Flexion PRACTICE Range of Motion Manual Muscle Testing Tibiofemoral Joint Play Testing FOUNDATIONAL TESTING Tibiofemoral Joint Play Testing FOUNDATIONAL TESTING Tibiofemoral Laxity Testing FOUNDATIONAL TESTING Tibiofemoral Laxity Testing FOUNDATIONAL TESTING PRACTICE Tibiofemoral Anterior Joint Play Tibiofemoral Posterior Joint Play Tibiofemoral Valgus Laxity Testing Tibiofemoral Varus Laxity Testing Patellofemoral Joint Play Testing FOUNDATIONAL TESTING Superior Glide Medial Glide/Tilt Inferior Glide Lateral Glide/Tilt PRACTICE Superior Patellar Glide Inferior Patellar Glide Medial Patellar Glide/Tilt Lateral Patellar Glide/Tilt Part Five: Special Tests and Measures Meniscal Tear (Posterior Horn) SPECIAL TESTING Left Non-Weight Bearing Flex/Ext Motion Meniscal Tear (Posterior Horn) SPECIAL TESTING Meniscus Weight Bearing Flex/Ext Motion Medial Meniscus Lateral PRACTICE McMurray’s Test Ege’s Test Meniscal Tear (Midsubstance) SPECIAL TESTING Non-Weight Bearing Rotational Motion Meniscal Tear (Midsubstance) SPECIAL TESTING Weight Bearing Rotational Motion Meniscal Tear (Midsubstance) SPECIAL TESTING Compression Rotational Motion PRACTICE Steinmann I Test Thessaly’s Test Meniscal Tear (Anterior Horn) SPECIAL TESTING Joint-line pain under the thumbs that increases during extension is considered a (+) test for anterior meniscal involvement. Meniscal Tear (End Feel) SPECIAL TESTING PRACTICE Steinmann I ITest Bounce Home ACL Tear SPECIAL TESTING ACL Tear SPECIAL TESTING Posterior-Lateral Corner Lesion SPECIAL TESTING Supine with Knees flexed to 30°** Standing at the foot of the patient Externally Rotate Both Legs (+) Excessive ER on Affected Side = Posterior Corner Lesion NA **Note: A Positive Dial Test at 80° is Suggestive of a PCL Tear. Antero-Lateral Rotatory Instability SPECIAL TESTING PRACTICE Anterior Drawer Lachman’s Test Dial Test Pivot Shift Test PCL Tear SPECIAL TESTING PCL Tear SPECIAL TESTING Postero-Lateral Rotatory Instability SPECIAL TESTING PRACTICE Posterior Drawer Posterior Sag Sign Reverse Pivot Shift Patellofemoral Dysfunction SPECIAL TESTING Patellofemoral Provocation SPECIAL TESTING Standing on a small step Standing near the side of the patient Patient steps the uninvolved leg down (+) Provocation of PFPS NA Pain Patellofemoral Instability SPECIAL TESTING Patellofemoral Compression SPECIAL TESTING Plica Compression SPECIAL TESTING PRACTICE Patellar Tilt Test Lateral Pull Test Clarke’s Patellar Grind Test Resisted Knee Extension Mital-Hayden Plica Test Sciatic Nerve Involvement SPECIAL TESTING Femoral Nerve Involvement SPECIAL TESTING PRACTICE Straight Leg Raise Test Side-lying Femoral Nerve Test Myotome Testing FOUNDATIONAL TESTING Perform Standing or Sitting Look for Strength and Provocation Hip Flexion (L1-2) Knee Extension (L3) Ankle Dorsiflexion (L4) 1st Toe Extension (L5) Plantar Flexion + Eversion (S1 ) Nerve Root Testing FOUNDATIONAL TESTING Reflex Testing Patellar (L3-4) Sensory Testing Achilles (S1) PRACTICE Myotome Testing Reflex Testing Sensory Testing Knee Snapshot Flexion 135° Tibiofemoral LP Tibiofemoral CP TF Cap Pattern Tibiofemoral OC Tibiofemoral CC Extension 0° 25° Full Extension + Tibial ER Flexion > Extension Arthrokinematics Concave on Convex Convex on Concave HOW DO WE CONDUCT AN EXAMINATION OF SOMEONE WITH KNEE DYSFUNCTION? Any questions? Q&A session