WEBVTT 00:00:00.029 --> 00:00:03.729 (English captions by Andrea Matsumoto from the University of Michigan) 00:00:03.729 --> 00:00:08.069 To ensure a thorough assessment it is best to preform the musculoskeletal exam of the 00:00:08.069 --> 00:00:10.139 knee in a systematic way. 00:00:10.139 --> 00:00:14.389 The following is a suggested order of exam that incorporates many of the common techniques 00:00:14.389 --> 00:00:18.089 used for evaluating knee injuries. 00:00:18.089 --> 00:00:22.007 Begin the exam with the patient in the standing position. 00:00:22.007 --> 00:00:27.071 Look for evidence of gross deformity, muscular atrophy, symmetry of the patellar alignment, 00:00:27.071 --> 00:00:32.329 evidence of varus or valgus positioning of the knee, or presence of pes planus or pes 00:00:32.329 --> 00:00:33.053 cavus of the foot. 00:00:33.053 --> 00:00:38.046 From a posterior view observe for more than two toes laterally, also called the "too 00:00:38.046 --> 00:00:39.899 many toes" sign. 00:00:39.899 --> 00:00:43.989 This can indicate an over-pronated foot or an abducted forefoot. 00:00:43.989 --> 00:00:47.005 Have the patient perform a toe raise and evaluate the heel position. 00:00:47.005 --> 00:00:55.739 Normally the heel should change from a neutral to a varus position. 00:00:55.739 --> 00:01:09.022 Next observe the gait looking for an antalgic gait or excessive pronation or supination. 00:01:09.022 --> 00:01:11.075 Next evaluate active range of motion. 00:01:11.075 --> 00:01:15.079 If pain or limitation exists repeat the range of motion passively. 00:01:15.079 --> 00:01:22.023 In a seated position test for knee extension. 00:01:22.023 --> 00:01:28.068 In this position also observe patellar tracking. 00:01:28.068 --> 00:01:36.093 And, internal and external rotation of the hip which can help identify referred knee 00:01:36.093 --> 00:01:41.017 pain caused by hip pathology. 00:01:41.017 --> 00:01:47.047 Also in the seated position, palpate anatomic landmarks for tenderness. 00:01:47.047 --> 00:02:05.034 Palpate the distal quadriceps, quadriceps tendon, the patella, patellar tendon, the 00:02:05.034 --> 00:02:14.095 tibial tuberosity, and the fat pads beneath the patella. 00:02:14.095 --> 00:02:36.079 On the medial side palpate the medial collateral ligament, the medial joint line, the pes anserine 00:02:36.079 --> 00:02:40.739 bursa. 00:02:40.739 --> 00:02:54.062 On the lateral side, the lateral collateral ligament, the lateral joint line, and the 00:02:54.062 --> 00:03:01.819 fibular head. 00:03:01.819 --> 00:03:16.139 Posteriorly palpate the popliteal fossa and the distal hamstrings. 00:03:16.139 --> 00:03:23.209 With the patient supine the leg can be fully extended to assess better for joint diffusion. 00:03:23.209 --> 00:03:27.409 Compress the suprapatellar pouch, pushing the contents distally, and assess for increased 00:03:27.409 --> 00:03:29.031 fluid. 00:03:29.031 --> 00:03:37.018 Patellar ballottement can also be performed by compressing the patella and releasing quickly. 00:03:37.018 --> 00:03:40.026 Observe for rapid rebound, which also indicated increased fluid pressure. 00:03:40.026 --> 00:03:46.018 If a click or tap is felt a large effusion is present, also called the ballottable patella. 00:03:46.018 --> 00:03:49.719 The patellar grind test assesses for patella-femoral syndrome. 00:03:49.719 --> 00:03:54.056 With the knee extended push the patella into the trochlear groove of the femur. 00:03:54.056 --> 00:03:57.709 Pain is a positive test. 00:03:57.709 --> 00:04:01.084 The patellar inhibition test assess for patella-femoral syndrome also. 00:04:01.084 --> 00:04:06.065 With the knee extended, push the superior aspect of the patella inferiorly as the patient 00:04:06.065 --> 00:04:08.939 tightens the quadriceps muscle. 00:04:08.939 --> 00:04:12.319 Pain or crepitus is considered a positive test. 00:04:12.319 --> 00:04:17.076 The patellar apprehension test evaluates for patellar subluxation of dislocation. 00:04:17.076 --> 00:04:22.088 With the knee extended push medially and laterally on the patella in an attempt to sublux the 00:04:22.088 --> 00:04:24.003 patella. 00:04:24.003 --> 00:04:30.054 If it is painful or the patient becomes apprehensive about the movement it is a positive test. 00:04:30.054 --> 00:04:34.061 There are several tests commonly performed to evaluate for ligamentous laxity of the 00:04:34.061 --> 00:04:37.014 knee. 00:04:37.014 --> 00:04:41.037 Medial collateral ligament stability can be tested at zero degrees and thirty degrees 00:04:41.037 --> 00:04:52.017 of flexion by applying a valgus force on the knee. 00:04:52.017 --> 00:04:56.051 Lateral collateral ligament stability can also be tested at zero degrees and thirty 00:04:56.051 --> 00:05:01.025 degrees of flexion by applying a varus force to the knee. 00:05:01.025 --> 00:05:06.091 Laxity indicates a partial or complete ligamentous tear. 00:05:06.091 --> 00:05:10.067 The Lachman�s test evaluates for a tear of the anterior cruciate ligament. 00:05:10.067 --> 00:05:17.007 With the knee flexed to thirty degrees, stabilize the femur and pull the proximal tibia anteriorly. 00:05:17.007 --> 00:05:24.027 Excessive motion or soft endpoint is a positive test. 00:05:24.027 --> 00:05:28.074 The anterior drawer test assesses of a tear of the anterior cruciate ligament also. 00:05:28.074 --> 00:05:32.093 With the knee flexed to ninety degrees and the foot planted on the table, push the proximal 00:05:32.093 --> 00:05:34.075 tibia anteriorly. 00:05:34.075 --> 00:05:39.051 Excessive motion or soft endpoint is a positive test. 00:05:39.051 --> 00:05:43.056 The posterior drawer test assesses for a tear of the posterior cruciate ligament. 00:05:43.056 --> 00:05:47.075 With the knee flexed at ninety degrees and the foot planted on the table, push the proximal 00:05:47.075 --> 00:05:49.069 tibia posteriorly. 00:05:49.069 --> 00:05:54.024 Excessive motion or a soft endpoint is a positive test. 00:05:54.024 --> 00:05:58.036 The PCL sag test evaluates for a tear of the posterior cruciate ligament. 00:05:58.036 --> 00:06:02.084 With both knees flexed to ninety degrees and feet planted on the table, view the knees 00:06:02.084 --> 00:06:06.062 from the side to compare the position of the tibia. 00:06:06.062 --> 00:06:10.046 Increased posterior sag of one of the tibias is considered a positive test. 00:06:10.046 --> 00:06:13.008 The McMurray�s test evaluates for a miniscule tear. 00:06:13.008 --> 00:06:18.016 With the patient supine and knee fully flexed, palpate the medial joint line and apply an 00:06:18.016 --> 00:06:22.008 axial force along the tibia while externally rotating and extending the knee. 00:06:22.008 --> 00:06:27.022 This maneuver is repeated palpating the lateral joint line while internally rotating the foot. 00:06:27.022 --> 00:06:31.061 Pain, catching, or palpable clunk indicates a miniscule tear. 00:06:31.061 --> 00:06:34.039 The bounce test also evaluates for a miniscule tear. 00:06:34.039 --> 00:06:39.033 Grasp the heel, extend, and bounce the leg, gently forcing hyperextension. 00:06:39.033 --> 00:06:41.074 Pain is a positive test. 00:06:41.074 --> 00:06:46.022 In the prone position, Apley�s compression test evaluates for a miniscule tear. 00:06:46.022 --> 00:06:50.087 Flex the knee to ninety degrees, apply an axial force along the tibia, and rotate the 00:06:50.087 --> 00:06:51.081 tibia. 00:06:51.081 --> 00:06:53.062 Pain is a positive test. 00:06:53.062 --> 00:06:57.003 Ober�s test assesses for iliotibial band syndrome. 00:06:57.003 --> 00:07:00.027 With the patient in the lateral position, the knee is supported and flexed to ninety 00:07:00.027 --> 00:07:01.018 degrees. 00:07:01.018 --> 00:07:06.008 Then extend and abduct the hip and release the knee support. 00:07:06.008 --> 00:07:09.096 Failure of the knee to adduct is a positive test. 00:07:09.096 --> 00:07:14.075 In the seated position, Noble�s test can also be used to evaluate for iliotibial band 00:07:14.075 --> 00:07:16.016 syndrome. 00:07:16.016 --> 00:07:20.011 With the knee flexed to ninety degrees, apply pressure over the lateral femoral chondral 00:07:20.011 --> 00:07:22.071 and passively extend the knee. 00:07:22.071 --> 00:07:27.004 Lateral pain around thirty degrees of flexion is a positive test. 00:07:27.004 --> 00:07:31.012 In concluding the knee exam, it's important to document a neurovascular exam. 00:07:31.012 --> 00:07:36.045 Here we demonstrate dorsalis pedis artery pulse, posterior tibial artery pulse, and 00:07:36.045 --> 00:07:38.032 capillary refill testing. 00:07:38.032 --> 00:07:42.234 A more thorough exam may be indicated based on patient history.