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Examination of the Knee. Thursday SM Conference August 21, 2008. Exam Settings. Sideline (on the field triage) Training room (post game eval) Office/clinic (delayed + detailed). The golden period (Golden opportunity…for good exam).

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examination of the knee

Examination of the Knee

Thursday SM Conference

August 21, 2008

exam settings
Exam Settings
  • Sideline (on the field triage)
  • Training room (post game eval)
  • Office/clinic (delayed + detailed)
the golden period golden opportunity for good exam
Thegoldenperiod(Golden opportunity…for good exam)
  • Fleeting minutes of minimal pain
  • No swelling
  • No muscle spasm
the golden period
The golden period
  • After soft tissue injuries
  • After initial shock of injury
  • Duration is 10-15 minutes
  • Maximum patient cooperation
sideline exam purpose determine disposition
Sideline ExamPurpose: determine disposition
  • Transfer (severe injury)
  • Hold out (mild – moderate)
    • Observe + re-examine
    • Provide first aide
  • Return to action (mild ?– no injury?)
case presentation
Case Presentation

22 year old collegiate wrestler

Contact injury to left knee

Medial-sided knee pain

sideline exam routine
Sideline Exam Routine
  • Determine mechanism
  • Point of maximum tenderness
  • Maneuver producing most pain
  • Determine severity of damage
slide8
Mechanism ?
    • Foot planted
    • Outside force
    • Pain + “pop”
sideline exam
Sideline Exam
  • Pain “on inside”
medial pain differential diagnoses
Medial Pain(Differential Diagnoses)
  • Medial Collateral Ligament sprain
  • Hamstring strain
  • Gastroc strain
  • Medial Meniscus tear
maximum tenderness
Maximum Tenderness?
  • Pain “on inside”
  • Tender over MCL
most painful maneuver
Most Painful maneuver?
  • Straight Valgus?
    • Straight
    • 30 degrees
  • External rotation?
sprain severity
Sprain Severity?
  • Classify by laxity
  • Best exam technique
    • One-handed
    • Two handed
check both sides
Check both sides!
  • Laxity normal ???
    • “Plastic man”
    • Post exercise
exam settings17
Exam Settings
  • Sideline Exam (on the field triage)
  • Training room (post game eval)
  • Office/clinic Exam
two handed technique
Two handed technique
  • Trap ankle on Iliac crest
  • Both hands on joint line
    • Palpate both joint lines

Stress X-ray

two handed technique22
Two handed technique
  • Trap ankle on Iliac crest
  • Both hands on joint line
    • Palpate both joint lines

Stress X-ray

collegiate football severity vs return
Collegiate footballSeverity vs. Return
  • Grade I – 10.6 days
  • Grade II – 19.5 days

Derscheid, G.L. and J.G. Garrick.

MCL injuries in football: Non-operative management of grade I and grade II sprains.

Am J Sports Med, 1981. 9(6): p. 365-8.

sideline estimate crowley albright 30 consecutive fb cases
Sideline estimate(Crowley-Albright 30 consecutive FB cases)

1 mm = 1 week

2 mm = 2 weeks

3 mm = 3 weeks

6 mm = 6 weeks

millimeters = weeks

time loss from sport
Time Loss From Sport
  • Severity of injury
  • Compliance??
exam settings27
Exam Settings
  • Sideline Exam (on the field triage)
  • Training room (post game eval)
  • Office/clinic Exam
office exam
Office Exam
  • What is important about the MCL exam?
    • Knee stability in full extension
knee hemarthrosis differential diagnosis
KneeHemarthrosisDifferential Diagnosis
  • ACL 70%
  • Meniscus 50%
  • Fracture 20%
  • Patellar dislocation
  • PCL
value of mri
Value of MRI?
  • When should an MRI be done?
    • When knowledge of location of injury might influence treatment
    • When additional injury is suspected
      • Instability at full extension should increase suspicion of cruciate injury
          • Mazzocca, A.D., et al., Valgus medial collateral ligament rupture causes concomitant loading and damage of the anterior cruciate ligament.
          • J Knee Surg, 2003. 16(3): p. 148-51.
location mcl tissue damage
Location MCL Tissue damage
  • Proximal ruptures heal more quickly than distal but have more stiffness
  • Complete ruptures can displace into the joint
  • Damage over entire ligament associated with persistent laxity after non-operative treatment
        • Nakamura, N., S. Horibe, et al. (2003). "Acute grade III MCL injury of the knee associated with ACL tear. usefulness of MRI in determining treatment regimen."
        • Am J Sports Med 31(2): 261-7.
grade iii gross instability laxity at full ext no endpoint
Grade III – Gross instabilityLaxity at full ext (no endpoint)

Indicates completerupture of MCL

  • Evaluate posteromedial capsule
  • Evaluate for cruciate injury
    • ACL
    • PCL
  • Evaluate for Patellar Dislocation