Diagnostic Evaluation of the Knee
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Q&A: Diagnosing a Swollen Knee
About this book Knee surgeons world wide have been aware that a beautifully illustrated book on diagnostic evaluation of the knee existed. Show all. Michael et al. Evaluation of the Ligaments Pages Strobel, Dr. All tests for meniscal and chondral lesions are a combination of knee flexion, tibial rotation and a stress on the joint line: this is the position where the posterior condyles roll back and the joint space becomes narrow, tightly engaging the menisci.
The tests can be dived in palpation test McMurray's, Bragard's, Steinmann's second, figure of four meniscal stress manoeuvre and rotation test Apley's, Bohler's, duck walking, Helfet's, Merke's, Payr's, Steimann's first [ 10 ]. In McMurray test the knee is flexed while the leg is externally rotated, palpating the joint line with a finger. Then, the knee is slowly extended.
The test for lateral meniscus is carried out by internally rotating the leg. In Bragard's test , external tibial rotation and knee extension bring the meniscus more anterior: if tenderness is felt along the joint line palpation, an articular surface irregularity i. In Steinmann's second test joint line tenderness migrates posteriorly with knee flexion and anteriorly with knee extension, following the movements of the meniscus. In the figure of four meniscal stress manoeuvre , the knee is held in a "figure of 4" Cabot's position, then the knee swings rapidly from a varus to a valgus stress, while a finger is pushed in the joint line.
Then the leg is twisted and pulled, then pushed. In Bohler's test a varus stress and a valgus stress are applied to the knee: pain is elicited by compression of the meniscal tear. Merke's test is similar to Thessaly test performed with the patient in a weightbearing position: pain with internal rotation of the body produces an external rotation of the tibia and medial joint line pain when medial meniscus is torn.
The opposite occurs when lateral meniscus is torn. In Helfet's test the knee is locked, and cannot rotate externally while extending, and the Q angle cannot reach normality with extension. In Peyr's test the patient is asked to sit in Turkish position, thus stressing the medial joint line: if the position raises pain, the test is positive for a medial meniscal lesion. Instability is usually defined with a direction anterior, posterior, medial, lateral, rotatory , which is the position the proximal tibia can abnormally reach, with respect to the distal femur. Many manoeuvres are available to rule out the type of instability and test the knee structures involved.
All tests can be divided in 4 groups: stress tests, slide tests, pivot shift jerk tests and rotational tests [ 6 , 9 , 10 , 12 ]. The standard stress tests include valgus abduction and varus adduction tests; additionally, Cabot manoeuvre is a commonly used stress test. Valgus Abduction stress test and Varus Adduction stress test are among the most known and used knee tests. The key point in performing these tests is taking care not to perform them carelessly.
Palpating the joint line with one finger can be useful to determine the amount of opening. Cabot's manoeuvre is another stress test, that evaluates the LCL. The knee is held in a 'figure of four' position, while giving a varus stress to the joint: the LCL, when intact, can be distinctively palpated as a tight chord stretched between the fibular head and the lateral epicondyle. While keeping the patient's knee in this position the figure of four meniscal stress manoeuvre can also be perfomed for details, see previously: figure of four meniscal stress manoeuvre. With these tests the examiner slides the tibia, trying to subluxate it from the distal femur.
Anterior and Posterior Drawer Test: the most commonly used test for ACL and PCL evaluation, they are easy to perform, but require some attention to avoid mistakes and for correct interpretation. Internal rotation tightens the PCL and the posterolateral corner, so that the anterior drawer can become negative in this position. Anterior and posterior drawer test are performed simultaneously, and the examiner has to take care to rule out the amount of anterior and posterior tibial translation.
Indeed in some cases when a PCL deficient knee has a posteriorized starting position, the reduction to a neutral postion can mimic an anterior drawer test: careful evaluation is required to avoid this mistake. In order to determine the correct starting point, palpation can be useful: in the neutral position the tibial plateau and the medial condyle face one another, with a slight anterior step-off of the tibia approximately 0.
The menisci can mimic a hard stop, giving a false negativity to the test, when they engage in the joint space under the femoral condyles during the anterior dislocation movement. The Lachman test is the test for ACL evaluation easier to be performed in all settings: it can be particularly useful in those cases when the knee is examined in the first days after injury, with the knee swollen and highly painful.
The use of mechanical quantification of the tibial translation with measure instruments such as the KT R is useful for follow-up but not for diagnostic purposes. Many test evaluate the tibial "sag", or subluxation, that can be encountered in PCL deficient knees: with the knee flexed, the tibia falls in a posterior subluxated potion; by contraction of the extensor apparatus this subluxation is reduced anteriorly. In these positions, a tibial draw back is noted particularly in the first position: Passive Tibial Sag sign.
Then the tibia is actively reduced by contraction the quadriceps muscle. In the Lachman-type position, the patient is asked to lift his leg against resistance Active Resisted Extension Test. In the drawer-type position, the patient is asked to lift his leg against resistance Active Resisted Extension Test II , or contraction of quadriceps muscle is obtained by evoking the patellar reflex Patellar Reflex Reduction Test.
These tests evaluate the rotatory instability that affects ACL deficient patients: this determines discomfort or frank pain with a shift or jerk of the knee joint, usually felt when squatting or changing direction. An isolated ACL rupture produces a slight shift, often highly uncomfortable for the patients, while a posterolateral corner lesion is required to determine a huge, visible and sometimes audible jerk. These tests are painful, and most of the times after the first attempt the test is no more reproducible, but they are the most effective in detecting an ACL rupture.
In the hours before the injury, as the knee starts to swell, the tests becomes more and more difficult to be performed, and painful, so it has to be carried out in the most acute setting or in the chronic one. McIntosh firstly described the test as the 'pivot shift' test McIntosh's Pivot Shift Jerk Test , quoting a hockey player with an unstable ACL deficient knee who reported: -when I pivot, my knee shifts-. In Noyes' Glide Pivot Shift Test the tibial subluxation is achieved not by internally rotating the leg, but rather by compressing the tibia axially towards the femur and lifting it anteriorly.
The examiner tries to dislocate the whole tibial plateau antero-posterior instability , not only the lateral aspect rotatory instability , so a 'glide', rather than a clear clunk is evoked. Hughston's Jerk Test produces the subluxation by extending the knee from the flexed position, applying the same valgus and internal rotation stress as in Noyes' test. The Slocum's Anterolateral Rotary Instability ALRI Test is performed with the patient on the side, in a semi-lateral position, resting on the unaffected limb, with the affected knee extended and the limb supported by only the heel resting on the examining table.
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In this position the foot and tibia rotate internally, translating anteriorly the lateral tibial plateau. Vertical valgus stress is applied to the knee, then the knee is progressively flexed. The position of the pelvis, held on the side and slightly posteriorly, avoids the rotational bias of the hip. The Reverse Pivot Shift Sign evokes the same shift as in pivot shift signs, but for PCL deficient knees: in these cases the lateral tibial plateau subluxes posteriorly when the tibia is stressed in external rotation and valgus, and reduces in extension.
The test can also be performed in the reverse direction, from the extended reduced position to the flexed subluxed one. These tests evaluate the posterolateral corner: a PLC deficient knee presents an external rotatory instability. PLC lesions are often associated to ACL or PCL tears, so it not uncommon to underestimate or misdiagnose a PLC lesion; the following tests are intended to electively evaluate the posterolateral corner [ 13 , 14 ]. The Tibial External Rotation Dial Test evaluates the amount of increased passive external rotation of the tibia in different positions of the knee.
The supine position is more comfortable for the patient, but in the prone position the hip is held in its position by the patient's weight, thus eliminating the rotator effect of the hip. Positivity is given by the combination of increased external rotation and hyperextension recurvatum.
Nontraumatic Knee Pain: A Diagnostic & Treatment Guide | Clinician Reviews
Different injury patterns show different tests positivity. A recent meta-analysis revealed limited evidence for the use of any specific physical exam tests to diagnose PFPS. But pain during squatting and pain with a patellar tilt test were most consistent with a diagnosis of PFPS. Conversely, the absence of pain during squatting or the absence of lateral retinacular pain helps rule it out.
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Radiography is not needed for a diagnosis but may be considered if examination reveals an effusion, the patient is 50 or older, or no improvement occurs after eight to 12 weeks of treatment. The most effective and strongly supported treatment for PFPS is a six-week physiotherapy program focusing on strengthening the quadriceps and hip muscles and stretching the quadriceps, ITB, hamstrings, and hip flexors. Patellar taping and bracing have shown some promise as adjunct therapies for PFPS, although the data for both are nonconclusive.
There is a paucity of prospective randomized trials of patellar bracing, and a Cochrane review found limited evidence of its efficacy. Taping or bracing may be useful when combined with a tailored physical therapy program. Evidence for treatments such as biofeedback, chiropractic manipulation, and orthotics is limited, and they should be used only as adjunctive therapy.
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When you examine Jane, you find no swelling of the affected knee. You perform the tilt test, which elicits pain.
Squatting causes some pain, as well. You diagnose PFPS and provide a referral for six weeks of physiotherapy. Here, too, stability of the joint is achieved with a combination of soft-tissue and bony restraints.
At full extension and early flexion of the knee, however, the mechanisms of stability are limited, resulting in increased instability. Other associated factors include Q-angle, lateral pull from a tight ITB, and opposing forces from the vastus lateralis and vastus medialis obliquus VMO.