KNEE

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CHAPTER ELEVEN KNEE

AXIOMS IN ASSESSING THE KNEE

• The knee consists of two joints: the patellofemoral and the tibiofemoral.
• Knee pain can arise from the joint itself, from periarticular tissues, or from the hip or femur.

INTRODUCTION

Pain is the most common presenting symptom of knee abnormalities. The causes of knee pain tend to be age related. A convenient way to classify knee pain complaints is by age group and by whether the pain is intraarticular, periarticular, or referred (Table 11-3).

TABLE 11-3 INTRAARTICULAR KNEE PAIN DIFFERENTIATED BY AGE

Age Intraarticular
Juvenile (2-10 yrs)
Juvenile chronic arthritis
Osteochondritis dissecans
Septic arthritis
Torn discoid lateral meniscus

Adolescent (10-18 years)
Osteochondritis dissecans
Torn meniscus
Anterior knee pain syndrome
Patellar malalignment
Early adult (18-30 yrs)
Torn meniscus
Instability
Anterior knee pain syndrome
Inflammatory conditions
Adult (30-50 yrs)
Degenerate meniscal tears
Early degeneration after injury or meniscectomy
Inflammatory arthropathies
Mature (>50 yrs)
Osteoarthritis
Inflammatory arthropathies

Adapted from Klippel JH, Dieppe PA: Rheumatology, vol 1-2, ed 2, London, 1998, Mosby.

TABLE 11-1 KNEE JOINT CROSS-REFERENCE TABLE BY ASSESSMENT PROCEDURE

image image image

TABLE 11-2 KNEE CROSS-REFERENCE TABLE BY SUSPECTED SYNDROME OR TISSUE

Anterior cruciate ligament
Drawer test
Lachman test
Lateral pivot shift maneuver
Slocum test
Arcuate-popliteus complex
Drawer test
Lachman test
Lateral pivot shift maneuver
Slocum test
Anterolateral rotary syndromes
Losee test
Q-angle test
Chondromalacia patella
Clarke test
Fouchet sign
Q-angle test
Effusion Patella ballottement test
Iliotibial band
Drawer test
Lateral pivot shift maneuver
Noble compression test
Slocum test
Lateral collateral ligament
Adduction stress test
Lateral pivot shift maneuver
Slocum test
Lateral meniscus
Apley compression/distraction test
Bounce home test
Clarke test
McMurray sign
Steinmann sign
Medial collateral ligament
Abduction stress test
Drawer test
Slocum test
Medial meniscus
Apley compression/distraction test
Bounce home test
Clarke test
McMurray sign
Payr sign
Steinmann sign
Osteochondritis Wilson sign
Patellar dislocation
Apprehension test for the patella
Q-angle test
Patellar fracture Dreyer sign
Patellar syndromes
Clarke test
Fouchet sign
Q-angle test
Posterior capsule
Drawer test
Lateral pivot shift maneuver
Slocum test
Posterior cruciate ligament
Drawer test
Slocum test
Posterior oblique ligament
Drawer test
Fouchet sign
Slocum test
Quadriceps Thigh circumference test
Valgus deformity Q-angle test

ORTHOPEDIC GAMUT 11-1 KNEE STABILITY

Knee stability depends on four ligaments:

1. Tibial collateral
2. Fibular collateral
3. Anterior cruciate
4. Posterior cruciate

The rounded contour of the femoral condyles furnishes little stability and the flat tibial plateaus, deepened by the semilunar cartilages. The quadriceps muscle and its tendinous expansions are great contributors to the stability and function of the knee. The earliest clinical indication of internal knee derangement is atrophy of the quadriceps.

The knee is not a true hinge joint. The tibia navigates a helical course on the condyles of the femur. Most traumatic arthritis of the knee in middle-age and elderly people results from minor derangements of the soft tissues, especially the menisci.

The knee lacks the stability of the hip, which has its ball and socket, or the ankle, which has its mortise and tendon. Both the hip and the ankle have structures that give some degree of bony stability. In the knee joint, the socket of the top of the tibia is so minimal that the lateral tibial plateau may be flat or even convex. The little bit of buffering provided by the menisci gives minimal increase in stability because the menisci are unstable themselves. For stability, the knee must depend largely on the soft tissues, ligaments, capsule, and muscles.

Making an accurate diagnosis about the exact nature of the patient’s knee injury is extremely important. Examination must determine what part of the knee is injured and how bad the injury is.

ORTHOPEDIC GAMUT 11-2 KNEE

Parts of a knee vulnerable to injury:

1. Ligaments
2. Muscle tendon
3. Capsule
4. Meniscus
5. Cartilage
6. Bone
7. Bursae
8. Any combination of these

ESSENTIAL ANATOMY

The knee joint is the articulation of the femur, patella, and tibia. The fibula is not involved in this articulation. The knee allows for flexion and extension and for rotation when the knee is in complete flexion but not if the knee is fully extended.

ORTHOPEDIC GAMUT 11-3 FABELLA

A fabella can be a source of:

• Fabellar pain syndrome
• Chondromalacia
• Fractures
• Symptomatic dislocation
• Osteoarthritis
• Hypertrophy causing peroneal nerve paralysis

ESSENTIAL MOTION ASSESSMENT

The flexion-extension movement of the knee is not a simple hinge motion (Figs. 11-1 and 11-2). As the knee passes through its degrees of flexion and extensions, the imaginary mediolateral axis through which the movement occurs shifts up and down on the femur.

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FIG. 11-1 The normal angle of knee flexion ranges from 130 to 150 degrees.

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FIG. 11-2 The knee should normally extend to a straight line (0 degrees) and can occasionally be hyperextended up to 15 degrees.

ESSENTIAL MUSCLE FUNCTION ASSESSMENT

The examiner tests the muscles responsible for knee flexion and extension, the hamstrings and quadriceps, respectively (Figs. 11-3 and 11-4).

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FIG. 11-3 The prime movers involved in flexion of the knee are the biceps femoris (sciatic nerve, tibial branch, S1, S2, and S3 to the long head; peroneal branch, L4, L5, S1, and S2 to the short head), semitendinosus (sciatic nerve, tibial branch, L4, L5, S1, S2, and S3), and the semimembranosus (sciatic nerve, tibial branch, L4, L5, S1, S2, and S3) muscles. The patient flexes the knee through its range of motion.

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FIG. 11-4 The prime mover involved in extension of the knee is the quadriceps femoris (rectus femoris, vastus intermedius, vastus medialis, and vastus lateralis) muscle (innervated by the femoral nerve, L2, L3, and L4). Extension of the knee is tested while the patient extends the knee through its range of motion.

ORTHOPEDIC GAMUT 11-4 THIGH MUSCLES

The three thigh muscles that attach to the medial side of the tibia (supplied by three different nerves) are the following:

1. Gracilis (obturator nerve)
2. Sartorius (femoral nerve)
3. Semitendinosus (tibial nerve)

ORTHOPEDIC GAMUT 11-5 SCIATIC NERVE

The sciatic nerve innervates the following:

1. Hip joint
2. Biceps femoris
3. Semitendinosus
4. Semimembranosus
5. Ischial head of the adductor magnus

ESSENTIAL IMAGING

The typical knee study consists of an anteroposterior (or posteroanterior) and a lateral view. Many examiners will include tangential, tunnel, or oblique views for further evaluation. The tangential view provides an axial depiction of the patella and its relationship with the femur. The tunnel allows excellent visualization of the intercondylar region of the femoral-tibial articulation.

ABDUCTION STRESS TEST

ALSO KNOWN AS VALGUS STRESS TEST

Assessment for Medial Collateral Ligament Injury

ORTHOPEDIC GAMUT 11-6 MEDIAL COLLATERAL LIGAMENT INJURY CLASSIFICATIONS

Grade I: 0 to 5 mm of joint opening with no instability
Grade II: 5 to 10 mm of joint opening with some degree of instability
Grade III: 10 to 15 mm of joint opening with moderate instability
Grade IV: Greater than 15 mm of joint opening with gross ligament instability

PROCEDURE

• While the patient is lying supine and the knee is in complete extension, the examiner, who is on the ipsilateral side, places one palm against the lateral aspect of the patient’s knee, at the joint line.
• While the other hand is gripping the ankle, the examiner laterally draws the leg to open the medial side of the joint (Fig. 11-5).
• If the patient is indifferent to this action, the examiner repeats it while the knee is in approximately 30 degrees of flexion, a position of lesser stability.
• This maneuver makes the medial joint vulnerable to torsion stress.
• The production or increase of pain, especially below, above, or at the joint line, is evidence of medial collateral ligament injury.
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FIG. 11-5

CLINICAL PEARL

The knee is an unusual joint because it contains ligaments deep within the joint. Medial and lateral collateral menisci in the joint can also be damaged. Finally, the normal motions of the knee are very complex, including two planes of rotation. Multiple and complex injuries are common.

ADDUCTION STRESS TEST

ALSO KNOWN AS VARUS STRESS TEST

Assessment for Lateral Collateral Ligament Injury

ORTHOPEDIC GAMUT 11-7 PROXIMAL TIBIOFIBULAR JOINT DYSFUNCTION SYMPTOMS

• Dull ache at the lateral aspect of the knee
• Pain radiating distally or proximally or both
• Hamstring tightness
• Knee and ankle movements that exacerbate the pain
• Pain that is relieved by rest
• Painful fibular head
• Full knee extension restricted or absent owing to hamstring tightness or pain

PROCEDURE

• While the patient is lying supine and the knee is in complete extension, the examiner, who is on the ipsilateral side, places one palm against the medial aspect of the patient’s knee, at the joint line.
• While the examiner’s other hand grasps the ankle, the examiner draws the leg medially to open the lateral side of the joint (Fig. 11-6).
• If the patient is indifferent to this procedure, the examiner repeats it with the knee in approximately 30 degrees of flexion.
• An initiation or increase of pain above, below, or at the joint line is evidence of lateral collateral ligament injury.
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FIG. 11-6

CLINICAL PEARL

Little congruency exists between the articular surfaces of the tibia and the femur. As a result, the knee has a well-developed system of ligaments for stability and an arrangement of intraarticular menisci that reduce the contact loading between the femur and the tibia.

APLEY COMPRESSION TEST

ALSO KNOWN AS APLEY DISTRACTION TEST AND APLEY GRINDING TEST

Assessment for Collateral Ligament Injury and Meniscus Tears

ORTHOPEDIC GAMUT 11-8 INDICATIONS OF PATHOLOGIC CONDITIONS OF THE MENISCUS

1. Pain or tenderness on the lateral surfaces of the knee joint
2. Popping, snapping, or grating sounds with movement
3. Inability to fully extend the knee (locking)

PROCEDURE

• The test involves four steps, and if any or all of these steps elicit knee pain or clicking, the test is positive.
• The patient is lying prone with the lower limbs straight and the ankles hanging over the end of the examination table.
• The examiner grasps the foot of the involved lower extremity, strongly rotates the leg internally and flexes the knee past 90 degrees.
• This maneuver is repeated with the leg strongly rotated in external rotation (Fig. 11-7).
• The examiner anchors the patient’s thigh to the examination table by placing a knee in the patient’s popliteal space.
• A small pillow or towel should be used for cushioning.
• The examiner strongly distracts the patient’s knee joint by lifting the foot.
• This move is followed by rapidly rotating the leg, both internally and externally (Fig. 11-8).
• This procedure is repeated with strong downward pressure on the patient’s foot.
• An intermediate maneuver may be performed.
• The examiner flexes the patient’s knee to 90 degrees and rapidly rotates the foot and leg both internally and externally without anchorage to rule out a rotational strain or collateral ligament tear.
• The test is significant for meniscus tear.
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FIG. 11-7

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FIG. 11-8

CLINICAL PEARL

The phrase internal derangement of the knee is a common provisional diagnosis for any patient with mechanical symptoms of the knee. The initials of this phrase, IDK, also stands for “I don’t know,” and the temptation to use these initials, instead of making a complete diagnosis, must be avoided.

APPREHENSION TEST FOR THE PATELLA

Assessment for Vulnerability to Recurrent Dislocation of the Patella

ORTHOPEDIC GAMUT 11-9 PREDISPOSING FACTORS FOR PATELLAR DISLOCATION

• High Q-angle
• Patella dysplasia
• Shallow trochlea
• Patella alta
• Lateral structure tightness
• Vastus medialis insufficiency
• Generalized joint laxity
• Femoral or tibial torsion
• Valgus knee

PROCEDURE

• The apprehension test for the patella is a test for vulnerability to recurrent dislocation of the patella.
• For the test, the patient is either supine or seated, with the quadriceps muscles relaxed.
• The knee is flexed to 30 degrees.
• The examiner carefully and slowly pushes the patella laterally (Fig. 11-9).
• If the patella feels as if it is about to dislocate, the patient will contract the quadriceps muscles and bring the patella back into line.
• This action indicates a positive test.
• The patient will also exhibit a look of apprehension.
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FIG. 11-9

CLINICAL PEARL

The examiner should observe for genu recurvatum and the position of the patella in relation to the femoral condyles. A high patella (patella alta) is a predisposing factor to recurrent lateral dislocation of the patella. The recurrent dislocation of the patella is also most common in women with the genu valgum deformity.

BOUNCE HOME TEST

Assessment for Meniscal Tears

ORTHOPEDIC GAMUT 11-10 CLASSIFICATIONS OF DISCOID MENISCUS

1. Complete, disk-shaped meniscus thin center; covers the tibial plateau
2. Incomplete, semilunar-shaped meniscus; partial tibial plateau coverage
3. Wrisberg-type, hypermobile meniscus caused by deficient posterior tibial attachment

PROCEDURE

• The patient is supine.
• The patient’s knee is flexed completely.
• The knee is allowed to drop into extension (Fig. 11-10).
• If the extension is not complete, the test is positive.
• The positive finding suggests a torn meniscus.
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FIG. 11-10

CLINICAL PEARL

Meniscus lesions are the most common internal derangement. Although the menisci are damaged by trauma, the incident is often so trivial that the patient cannot remember any injury at all. Because of this circumstance, patients with meniscal injuries are rarely seen in emergency rooms.

CHILDRESS DUCK WADDLE TEST

Assessment for Medial or Lateral Meniscus Tears

ORTHOPEDIC GAMUT 11-11 COMMON MENISCAL TEARS TYPE

1. Type I: splitting of the meniscus, along its longitudinal axis, producing the so-called bucket-handle tear
2. Type II: a tear along transverse axis of the meniscus

PROCEDURE

• The patient stands with the feet somewhat apart and the legs in maximal internal rotation.
• A full squat is attempted (Fig. 11-11).
• During this maneuver, the patient’s heels may come up from the floor, with weight bearing passing to the balls of the feet.
• The maneuver is repeated, with the lower limbs in maximal external rotation (Fig. 11-12).
• A positive test consists of pain, inability to fully flex the knee, or a clicking sound on either posterior side of the joint.
• The test is significant during internal rotation for a medial meniscus tear or during external rotation for a lateral meniscus tear.
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FIG. 11-11

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FIG. 11-12

CLINICAL PEARL

The menisci are important parts of the load-bearing mechanism of the knee because they absorb the downward thrust of the convex femoral condyles. The menisci are so effective that, if they are removed, the force that is taken by the articular cartilage during peak loading increases approximately five times. Therefore, a meniscectomy exposes the articular cartilage to much greater forces than normal. Evidence of degenerative osteoarthritis is seen in 75% of patients 10 years after a total meniscectomy.

CLARKE SIGN

Assessment for Chondromalacia Patellae

ORTHOPEDIC GAMUT 11-12 THREE GROUPS OF PATELLAR MALACIA

1. Group I is trauma related.

a. A chondral fracture or infraction may exist caused either by acute trauma or by repeated, lesser traumata to the patella.
b. Infraction of the patellar cartilage causes irritation of the patellar groove on the femur, and gradual changes supervene with fissuring, absorption, and fragmentation of the cartilage.

2. Group II is associated with a disturbance of the rhythm of the patellar function.

a. These disturbances are commonly called tracking disorders.
b. This is the type of malacia that accompanies intrinsic injury to the knee.
c. Any condition that causes a disturbance in the rhythm of the knee action often results in involvement of the undersurface of the patella.
d. The knee is checked abruptly, motion is reversed, and the patella is driven against the femur.
e. A relationship exists between the locking of the knee and the degree of malacia present.
f. These two factors are much more important for indicating the amount of malacia present than is the age of the patient.
g. The exact mechanism of the breakdown of the patella has never been wholly explained.
h. This condition also probably occurs as the result of various other causes, including direct trauma and synovitis of the joint and general chondrolytic changes.
i. The particular pathologic changes described usually accompany other intrinsic conditions of the knee.

3. Group III is primary malacia of the patella, usually a bilateral condition, without any demonstrable etiologic factor.

a. These cases are puzzling.
b. The examiner cannot rule out the effect of repeated trauma because young patients are usually very physically active.
c. These patients should be expected to traumatize the patella repeatedly.
d. However, the simultaneous involvement of both knees, with relative lack of involvement of other chondral surfaces equally susceptible to trauma, prompts the examiner to seek a cause other than a simple contusion.

ORTHOPEDIC GAMUT 11-13 ETIOLOGY OF CHONDROMALACIA PATELLA

1. Any injury or anatomic abnormality that predisposes the area to an irregular pattern of movement of the patella
2. Meniscus injuries that alter normal tibiofemoral motion
3. Recurrent subluxation of the patella
4. Quadriceps imbalance
5. Patella alta
6. Angular deformities of the knee
7. Direct trauma to the patella

PROCEDURE

• The patient’s knee is extended fully.
• The examiner compresses the quadriceps muscles at the superior pole of the patella.
• The patient gently contracts the quadriceps muscles as the examiner resists the movement of the patella (Fig. 11-13).
• Retropatellar pain and failure to hold the contraction is considered positive.
• A positive test suggests chondromalacia patella.
• To test different parts of the patella, the knee should be tested in 30, 60, and 90 degrees of flexion and in full extension.
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FIG. 11-13

CLINICAL PEARL

In examining the patella, the examiner should note any tenderness over the anterior surface and whether a bipartite ridge is present. Upper and lower pole tenderness occurs in Sinding-Larsen-Johansson disease and jumper’s knee (an extensor apparatus traction injury).

DRAWER TEST

Assessment for Injury to Some Degree of (1) the Anterior Cruciate Ligament, Especially the Anteromedial Bundle, (2) the Posterolateral Capsule, (3) the Posteromedial Capsule, (4) the Medial Collateral Ligament, Especially the Deep Fibers, (5) the Iliotibial Band, (6) the Posterior Oblique Ligament, (7) the Arcuate-Popliteus Complex, and (8) the Posterior Cruciate Ligament (in Testing Posterior Drawer Movements)

ORTHOPEDIC GAMUT 11-14 GRADES OF KNEE LIGAMENT SPRAINS

1. Mild—grade I, first-degree ligament sprain: an incomplete stretching of collagen ligament fibers, resulting in minimal pain, minimal or no swelling, no loss of joint function, and no clinical or functional instability.
2. Moderate—grade II, second-degree ligament sprain: a partial loss of ligament fiber continuity. A few collagen ligament fibers may be completely torn; however, most of the ligament remains intact. This degree of sprain is characterized by moderate (more intense than a first-degree sprain) pain, moderate swelling, some loss of joint function, and some loss of joint stability.
3. Severe—grade III, third-degree sprain (rupture): the entire collagen ligament fiber bundles are completely torn. No continuity exists within the body of the ligament. This injury is usually characterized by profound pain, intense swelling, loss of joint function, and instability.

ORTHOPEDIC GAMUT 11-15 HUGHSTON KNEE INSTABILITIES INDEX

1. Mild instability: graded 1+ (5 mm or less of joint surface separation)
2. Moderate instability: graded 2+ (joint surface separation of 4 to 10 mm)
3. Severe instability: graded 3+ (joint surface separation of 10 mm or more)

ORTHOPEDIC GAMUT 11-16 POSITIVE ANTERIOR DRAWER TEST

In a positive anterior drawer test, the following structures may have been injured to some degree:

1. Anterior cruciate ligament, especially the anteromedial bundle
2. Posterolateral capsule
3. Posteromedial capsule
4. Medial collateral ligament, especially the deep fibers
5. Iliotibial band
6. Posterior oblique ligament
7. Arcuate-popliteus complex

ORTHOPEDIC GAMUT 11-17 COMMON TYPES OF POSTERIOR CRUCIATE LIGAMENT TEARS

1. The medial tibial condyle subluxates anteriorly (anteromedial instability).
2. The lateral tibial condyle subluxates anteriorly (anterolateral rotary instability).
3. The lateral tibial condyle subluxates posteriorly (posterolateral rotary instability).
4. Combinations of these lesions may be found.

ORTHOPEDIC GAMUT 11-18 POSITIVE POSTERIOR DRAWER TEST

In a positive posterior drawer test, the following structures may have been injured to some degree:

1. Posterior cruciate ligament
2. Arcuate-popliteus complex
3. Posterior oblique ligament
4. Anterior cruciate ligament

PROCEDURE

• The patient’s knee is flexed to 90 degrees.
• The patient’s foot is held on the table by the examiner.
• The tibia is pulled forward on the femur by placing hands around the tibia (Fig. 11-14).
• Normal movement is approximately 6 mm.
• When the tibia moves forward more than 6 mm on the femur, the test is positive.
• To test the posterior cruciate ligament (PCL), the tibia is pushed back on the femur (Fig. 11-15).
• The test is positive when excessive movement is noted.
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FIG. 11-14

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FIG. 11-15

CLINICAL PEARL

A tibia that is already displaced backward, as a result of a posterior cruciate tear, may give a false-positive result when the examiner is testing the anterior cruciate. This false-positive test may also occur with the Lachman test.

DREYER SIGN

Assessment for Fracture of the Patella

ORTHOPEDIC GAMUT 11-19 ORTIGUERA AND BERRY CLASSIFICATION OF PERIPROSTHETIC FRACTURES OF THE PATELLA

1. Type I: intact extensor mechanism; stable implant
2. Type II: disruption of extensor mechanism; with or without implant in place
3. Type III: intact extensor mechanism
a. Loosening of patellar component
b. Reasonable remaining bone stock
c. Poor bone stock

PROCEDURE

• While lying supine with the knee extended, the patient is unable to raise the leg.
• When the examiner applies compression to the thigh, by using the hands to give anchorage to the quadriceps, the patient is able to lift the leg (Fig. 11-16).
• When this force is removed, the patient is again unable to raise the leg.
• The test is significant for a fracture of the patella.
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FIG. 11-16

CLINICAL PEARL

The quadriceps muscle gains insertion into the tibia through the medium of the patella, which is enclosed within the quadriceps expansion and the patellar tendon. Complete rupture may occur as a disruption through the patella. This area is the usual site of rupture for a common variety of fractured patella. The injury occurs mainly in adults of middle age.

FOUCHET SIGN

Assessment for Patellar Tracking Disorder, Peripatellar Syndrome, or Patellofemoral Dysfunction

ORTHOPEDIC GAMUT 11-20 PATHOMECHANICS OF PATELLOFEMORAL DISORDERS

1. Q-angle
2. Lateral retinacular tightness
3. Vastus medialis obliquus deficiency
4. Lateral deviation of the patella at terminal extension (J-sign)
5. Patella alta or infera
6. Trochlear depth
7. Congruence of the patellofemoral joint

ORTHOPEDIC GAMUT 11-21 DEJOUR’S CLASSIFICATION OF EXTENSOR MECHANISM MALALIGNMENT

• Major patellar instability; more than one documented dislocation
• Objective patellar instability; one dislocation with associated anatomic abnormalities
• Potential patellar instability; patellar pain with associated radiologic abnormalities

PROCEDURE

• While the patient is lying supine and the knee is in full extension, the examiner uses the flat of a hand to compress the patella against the femur (Fig. 11-17).
• If this action produces point tenderness and pain at the patellar margin, the sign is present.
• If pain is not produced by this maneuver, the examiner then rubs the patella transversely against the femur.
• Audible or palpable grating and pain confirm the presence of the sign.
• When the patella has peripheral tenderness on medial or lateral displacement, this is known as Perkins sign.
• Perkins sign is significant for patellar tracking disorder, peripatellar syndrome, or patellofemoral dysfunction.
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FIG. 11-17

CLINICAL PEARL

Placing a palm of the hand over the patient’s patella and the thumb and index finger along the joint line as the joint is flexed and extended will distinguish the source of the crepitus from damaged articular surfaces.

LACHMAN TEST

Assessment for Injury to Some Degree of (1) the Anterior Cruciate Ligament, Especially the Posterolateral Bundle, (2) the Posterior Oblique Ligament, and (3) the Arcuate-Popliteus Complex

PROCEDURE

• The patient is supine.
• The patient’s knee is held between full extension and 30 degrees of flexion.
• The patient’s femur is stabilized with one hand as the tibia is moved forward (Fig. 11-18).
• A mushy, or soft, end-feel when the tibia is moved forward on the femur and the infrapatellar tendon slope disappears is a positive sign.
• A positive sign suggests damage to (1) the anterior cruciate ligament (ACL), especially the posterolateral bundle, (2) the posterior oblique ligament, and (3) the arcuate-popliteus complex.
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FIG. 11-18

CLINICAL PEARL

When medial and lateral or anterior and posterior, as well as the medial and lateral, compartments are torn, combined complex instability exists. Transitory dislocation, or at least subluxation of the knee, is a preliminary symptom. In many instances, the peroneal nerve has been injured.

LATERAL PIVOT SHIFT MANEUVER

ALSO KNOWN AS TEST OF MCINTOSH

Assessment for Injury to Some Degree of (1) the Anterior Cruciate Ligament, (2) the Posterolateral Capsule, (3) the Arcuate-Popliteus Complex, (4) the Lateral Collateral Ligament, and (5) the Iliotibial Band

PROCEDURE

• The patient is supine.
• The examiner flexes the knee slightly (5 degrees).
• A valgus stress is applied to the knee while maintaining a medial rotation torque on the tibia and at the ankle.
• The leg is flexed 30 to 40 degrees. The tibia reduces or jogs backward.
• The patient experiences the sensation of the knee giving way (Fig. 11-19).
• This sensation is the positive finding.
• To some degree, (1) the ACL, (2) the posterolateral capsule, (3) the arcuate-popliteus complex, (4) the lateral collateral ligament, or (5) the iliotibial band has been injured.
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FIG. 11-19

CLINICAL PEARL

Normally, the knee’s center of rotation changes constantly through its range of motion as a result of the shape of the femoral condyles, the ligamentous restraint, and the muscle pull. A positive pivot shift test usually suggests damage to the anterior cruciate, the posterior capsule, or the lateral collateral ligament.

LOSEE TEST

Assessment for Anterolateral Rotary Instability of the Knee

PROCEDURE

• The patient is in a supine position.
• The patient’s leg is externally rotated.
• The patient’s knee is flexed to 30 degrees.
• The examiner hooks a thumb behind the patient’s fibular head.
• A valgus force is applied to the knee.
• The knee is extended, and forward pressure is applied behind the fibular head with the examiner’s thumb (Fig. 11-20).
• The leg moves into medial rotation.
• If a clunk is felt forward just before full extension of the knee, the test is positive.
• This clunk means that the tibia has subluxed anteriorly and indicates injury to the same structures listed with the lateral pivot shift maneuver.
• The Losee test assesses anterolateral rotary instability.
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FIG. 11-20

CLINICAL PEARL

If rotary instability is present, then as full extension is reached, a dramatic clunk will occur as the lateral tibial condyle subluxates forward. The patient should relate this information to the sensations experienced during activity.

MCMURRAY SIGN

Assessment for Medial or Lateral Meniscus Injury

PROCEDURE

• The patient is lying supine, and the thigh and leg are flexed until the heel approaches the buttock.
• One of the examiner’s hands is on the knee, and the other is on the heel.
• The examiner internally rotates and slowly extends the leg (Fig. 11-21).
• The examiner then externally rotates and slowly extends the leg.
• McMurray sign is present if, at some point in the arc, a painful click or snap is heard.
• This sign is significant in meniscal injury.
• The point in the arc at which the snap is heard locates the site of injury of the meniscus.
• If noted with internal rotation, the lateral meniscus will be involved.
• The higher the leg is raised when the snap is heard, the more posterior the lesion is in the meniscus.
• If noted with external rotation, the medial meniscus will be involved.
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FIG. 11-21

CLINICAL PEARL

The examiner should observe for tenderness in the joint line and test for a springy block to full extension of the knee. These two signs, in association with evidence of quadriceps atrophy, are the most consistent and reliable signs of a torn meniscus.

NOBLE COMPRESSION TEST

Assessment for Iliotibial Band Friction Syndrome

ORTHOPEDIC GAMUT 11-22 EXTRINSIC AND INTRINSIC CAUSATIVE FACTORS OF ILIOTIBIAL BAND FRICTION SYNDROME

EXTRINSIC FACTORS

1. Running or cycling on an oblique surface causing a pelvic tilt
2. Sudden increase in running or cycling distance
3. Improper seating with cleats too far internally rotated or a saddle that is not well positioned

INTRINSIC FACTORS

1. Varus knee deformity that predisposes the area for this friction syndrome between the lateral femoral epicondyle and the overriding iliotibial band
2. Leg-length discrepancy
3. Forefoot pronation

PROCEDURE

• The patient is in a supine position.
• The patient’s hip and knee are flexed 90 degrees.
• The examiner applies thumb pressure to the lateral femoral condyle.
• The patient’s knee is extended as the thumb pressure is maintained.
• In the positive test, the patient will complain of severe pain over the lateral femoral condyle, near 30 degrees of flexion (Fig. 11-22).
• This pain indicates iliotibial band syndrome.
image

FIG. 11-22

CLINICAL PEARL

This syndrome produces a line of tenderness that extends from the anterolateral tibia, across the joint line, and up the side of the thigh. Tenderness is usually maximal over the lateral femoral condyle, and a painful arc occurs at approximately 30 degrees of flexion.

PATELLA BALLOTTEMENT TEST

Assessment for Joint Effusion

PROCEDURE

• The patient’s knee is extended.
• A slight tap or pressure is applied over the patella (Fig. 11-23).
• This test is positive if a large amount of swelling in the knee is detected.
image

FIG. 11-23

CLINICAL PEARL

If popliteal swelling is found, confirming communication with the joint is possible by massaging its contents back into the main synovial cavity while the knee is in flexion. The examiner maintains pressure on the patient’s popliteal fossa, extends the knee, and then removes the pressure. The swelling will not reappear until the patient flexes the knee several times, confirming a valve-like communication between the main cavity and the cyst.

PAYR SIGN

Assessment for Injury of the Posterior Horn of the Medial Meniscus

PROCEDURE

• The patient is in the cross-legged, yoga-seated position, with the feet and ankles crossed.
• The examiner applies downward pressure on the knee joint (Fig. 11-24).
• Pain is elicited on the medial side of the joint when the sign is present.
• The test is significant when a lesion of the posterior horn of the medial meniscus is present.
image

FIG. 11-24

CLINICAL PEARL

Meniscal cysts lie in the joint line, feel firm during palpation, and are tender to deep pressure. Cysts of the menisci may be associated with tears. Lateral meniscus cysts are by far the most common. Cystic swellings on the medial side are sometimes caused by ganglions that arise from the pes anserinus (insertion of the sartorius, gracilis, and semitendinosus).

Q-ANGLE TEST

Assessment for Patellofemoral Dysfunction, Patella Alta, Subluxating Patella, Increased Femoral Anteversion, Genu Valgum, or Increased Lateral Tibial Torsion

PROCEDURE

• To determine the Q-angle, a line is drawn from the anterosuperior iliac spine to the midpoint of the patella and from the tibial tubercle to the midpoint of the patella.
• The angle formed by the intersection of these two lines is the Q-angle (Fig. 11-25).
• Normally, the Q-angle is 13 to 18 degrees. The normal angle for men is 13 degrees, and for women it is 18 degrees.
• Less than 13 degrees suggests patellofemoral dysfunction or patella alta.
• Greater than 18 degrees suggests patellofemoral dysfunction, subluxating patella, increased femoral anteversion, genu valgum, or increased lateral tibial torsion.
image

FIG. 11-25

CLINICAL PEARL

In children, an increased Q-angle is associated with genu valgum. The examiner must note whether the genu valgum is unilateral or, as is usual, bilateral. The severity of the deformity is recorded by measuring the intermalleolar gap. The examiner grasps the child’s ankles and rotates the legs until the patellae are vertical. The legs are brought together to touch lightly at the knees. A measurement is made between the malleoli. Serial measurements, often every 6 months, are used to check progress. Note that, with growth, a static measurement is an angular improvement.

SLOCUM TEST

Assessment for Anterolateral Rotary Instability, with Injury to Some Degree of (1) the Anterior Cruciate Ligament, (2) the Posterolateral Capsule, (3) the Arcuate-Popliteus Complex, (4) the Lateral Collateral Ligament, (5) the Posterior Cruciate Ligament, and (6) the Iliotibial Band (Tensor Fascia Lata)

PROCEDURE

• The patient is setting in supine position.
• The knee is flexed to 80 or 90 degrees; the hip is flexed to 45 degrees.
• The foot is internally rotated.
• The foot is held as the tibia is pulled anteriorly.
• Movement will occur on the lateral side of the knee if the test is positive.
• This movement indicates anterolateral rotatory instability.
• Excessive movement suggests injury to (1) the ACL, (2) the posterolateral capsule, (3) the arcuate-popliteus complex, (4) the lateral collateral ligament, (5) the PCL, or (6) the iliotibial band.
• The test also may be performed while the patient is seated with the knees flexed over the edge of the examination table.
• The examiner pulls or pushes the tibia to the knee while medially or laterally rotating the foot (Fig. 11-26).
• Pulling on the tibia tests for anterior rotary instability. Pushing the tibia tests for posterior rotary instability.
image

FIG. 11-26

CLINICAL PEARL

This maneuver tightens the lateral capsule, giving enough stability to eliminate the anterior drawer sign. If the anterior drawer sign is still positive while the patient is in this position (most anterior movement occurring on the lateral side), the lateral capsule (or lateral collateral ligament) is likely also damaged.

STEINMANN SIGN

ALSO KNOWN AS STEINMANN TENDERNESS DISPLACEMENT TEST

Assessment for Lateral or Medial Meniscus Tear

ORTHOPEDIC GAMUT 11-23 FACTORS CONTRIBUTING TO MENISCUS TEAR

1. The knee must be bearing weight.
2. The knee must be flexed.
3. A rotation strain is required.

PROCEDURE

• Knee pain moves anteriorly when the knee is extended and moves posteriorly when the knee is flexed (Fig. 11-27).
• The movement of pain is the positive sign.
• This sign indicates a meniscus tear.
• Medial pain is elicited by lateral rotation.
• Lateral pain is elicited by medial rotation.
image

FIG. 11-27

CLINICAL PEARL

Patients use the term locking to describe episodes of severe pain in the knee or even collapsing of the knee. Curiously, the word is not applied in this way to any other joints. Locking denotes mechanical jamming of the knee joint and nothing more.

THIGH CIRCUMFERENCE TEST

Assessment for Muscle Hypertonicity or Hypotonicity of the Thigh

ORTHOPEDIC GAMUT 11-24 RISK FACTORS FOR PATELLAR OR QUADRICEPS RUPTURE

• Diabetes mellitus
• Gout
• Repetitive microtrauma
• Endocrine disorders

PROCEDURE

• An area of the thigh 10 cm above the patella is identified.
• The circumference of the leg at that point is measured and compared with the opposite leg (Fig. 11-28).
image

FIG. 11-28

CLINICAL PEARL

Although all the quadriceps muscle atrophies uniformly, atrophy of the bulky vastus medialis (particularly in a fit young man) may be the most conspicuous. Quadriceps atrophy is a difficult sign to detect, particularly in the middle-age, elderly, and female patients. Some asymmetry of muscle bulk is common.

WILSON SIGN

Assessment for Osteochondritis Dissecans of the Knee

ORTHOPEDIC GAMUT 11-25 COMMON ORIGINS OF A LOOSE BODY IN THE KNEE

• Osteochondritis dissecans at the lateral border of the medial femoral condyle (men)
• Marginal fracture that is from the lateral margin of the lateral femoral condyle and is secondary to direct trauma or patellar dislocation (men)
• Medial tangential osteochondral fracture of the patella from dislocation (men)
• This order is reversed in the female patient.

ORTHOPEDIC GAMUT 11-26 COMMON SITES FOR OSTEOCHONDRITIS DISSECANS

1. The lateral border of the medial femoral condyle
2. The inferior, central area of the lateral femoral condyle
3. The inferior, central region of the medial femoral condyle

ORTHOPEDIC GAMUT 11-27 POSSIBLE CONTRIBUTORY FACTORS FOR OSTEOCHONDRITIS DISSECANS

• Trauma
• Ischemia
• Ossification defects
• Epiphyseal dysplasia
• Family history

PROCEDURE

• The patient is in a supine position.
• The patient’s knee is flexed to 90 degrees by the examiner.
• The knee is extended with the tibia medially rotated.
• Near 30 degrees of flexion, pain in the knee increases (the patient often stops the rotating movement).
• If the tibia is rotated laterally, the pain disappears, which is a positive test (Fig. 11-29).
• The positive test indicates osteochondritis dissecans of the femur.
image

FIG. 11-29

CLINICAL PEARL

Patients often give a classic account of a loose fragment in the knee and are usually able to describe its size and shape. Loose bodies are sometimes called joint mice, which is an appropriate description because these loose bodies can be recognized instantly, but they disappear and may be impossible to find again. Loose bodies should not be called foreign bodies. Foreign bodies, including bullets and bits of gravel, come from outside the body and are rare in joints.

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