History

• Past History
  • When? Where? How many times? Managed how? Swelling?
• Present History
  • Chief complaint? Where? Mechanism (if possible)?
  • Pick questions carefully
  • Avoid “leading” questions
    • Single trauma?
    • Sensation?

      NOT: “Did it snap when it happened?”

      INSTEAD: “What did it feel like?”

    • Contact?

      Unreliable in many cases

  • Repetitive stress?
  • Establish the mechanism
    • Single Trauma

      Contact

      Common perception is that serious knee injuries happen only when there's a contact.

      Non-contact

      It could happen even when no one touches the player. Often times the athlete “swears” that there was a contact even if the video shows otherwise.

    • Repetitive Trauma

Inspection

• Note deformity, inflammation, effusion.

  Bursitis, fat pad irritation, tendinitis, etc.

• Note muscle tone and unusual appearance.

  Atrophy of VMO in particular

  Patella Alta/Baja

• Compare affected and unaffected sides.

Palpation

• Check deformity
  • Note swelling, Crepitis, warmth, structural integrity, etc.

    Away from the injured area first

    Once the injured site is touched and pain threshold is reached, the assessment accuracy may be affected.

    Palpation of unaffected side may be warranted.

• No excuses!
  • Mastery of the following subjects is a PREREQUISITE to accurate injury assessment

    Knowledge of surface anatomy

    Knowledge of functional anatomy

    Knowledge of joint biomechanics

    Ability to reason

    Ability to prioritize

Testing

• AROM
  1. Unable
  2. Assess severity.
  3. Able but incomplete
     • Lack of ROM due to joint structure?
     • Lack of ROM due to affected muscles?
     • Lack of ROM due to pain?
  4. Complete
• RROM (Not critical in field assessment)
  1. Extension
  2. Flexion
  3. (Internal/External rotation)
  4. Adduction (hip)
  5. Abduction (hip)
• PROM
  1. Normal flexion PROM differs from AROM or RROM...WHY???
  2. If AROM lacks last few degrees of extension but PROM is normal, what could be the problem?
• Neurological exam
  • Patellar tendon reflex
  • Dermatome
• Vascular exam (Lack of blood supply to the leg/foot is a distinct possibility following a tibiofemoral dislocation )
  • Tibial pulse
  • Dorsalis pedis
• Orthopedic exam
  • Valgus (Knee flexed 30 degrees and full extension) - MCL and capsule
  • Lachman - ACL
    1. The knee is held at 20-25 degrees flexion.
    2. Force is applied along the plane of tibial plateau.

    Signs of ACL Tear

    (+) Lachman

    (+) Pivot shift

    Hemarthrosis (blood in the knee)

    Marked swelling

    “It ballooned up and I couldnt even see the outline of knee cap, then the swelling went down slowly.” (past history)

    Prognosis for ACL tear

    Likely to develop rotatory instability

    Progressively become worse

    • Autograft (own tissue) ACL reconstructive surgery
      • Patellar tendon
      • Semitendinosus
    • Allograft (someone else's tissue) ACL reconstructive surgery
      • IT-band
      • Synthetic material
  • McMurray - meniscus
    1. Fingers placed on joint line
    2. Passively take the knee to FULL flexion and extension as it is internally and externally rotated.
    3. Consistent clicking/pain and/or the feeling of “pop” at the joint line (your fingers) should be considered positive.
    • About 1/2 of meniscus tears have negative McMurray.
    • Clinical signs and symptoms are more reliable than McMurray.

      They are:

      Pain at the joint line

      Lack of ROM toward the end of range

      Difficulty with closed kinematic chain flexion, such as squats.

      Consistent clicking

      Past injury and subsequent rotatory instability

  • Pivot shift - ALRI (ACL)
    • Checks rotatory instability
    • Uncomfortable and difficult to replicate after initial attempt.
    • ALRI & AMRI after ACL injury

      If muscular strength and endurance are not maintained,

      They will become progressively worse

      They will progressively damage the structures

      1. ACL and/or PCL first
      2. Capsule
      3. Menisci
      4. Joint surfaces -- osteoarthritis

  • Anterior drawer - ACL/capsule
    1. The knee is held at 90 degrees flexion.
    2. Tibia is pulled forward along the plane of tibial plateau.
  • Godfrey - posterior cruciate
    1. The knee is held at 90 degrees flexion.
    2. The line of patella and tibial tuberosity are compared between the injured and uninjured sides.
    3. If the tibial tuberosity is “sagged,” there is a posterior cruciate insufficiency.
    • Relationship between anterior drawer test and PCL injury

      PCL injuries may exhibit (+) anterior drawer sign because the tibia is already sagged and the examiner is pulling the leg forward to reduce it. The increased excursion of the tibia may be falsely identified as the ACL insufficiency.

    • Prognosis

      Similar to ACL injuries

  • Slocum
  • Varus
  • (Apleys compression/distraction)
    • Not quite discriminatory.
  • Patellar crunch
    1. Move the knee throughout the ROM
    2. At various points of ROM, use the palm and push and grind the patella against the femoral groove.
    • If pain and crepitis are produced, the test is (+)
  • Patellar apprehension
    1. Athlete is supine and the knee is in full extension
    2. Move the patella laterally and watch the reaction of the athlete (face and the quadriceps)
    3. If the quadriceps contract on forceful movement and the facial expression changes, the sign is positive.
    • If positive, the athlete had prior episode(s) of patellar subluxation/dislocation.

    - Predisposing Conditions

    Weak vastus medialis

    Previous episodes of knee injury

    Large Q-Angle

    Loose retinaculum

    Patella Alta

  • Bounce and minor effusion check
  • (Decisions for immediate care & referral)