1. When did the injury occur?

2. How did it happen? (etiology)

a) were you planted? turned/twisted?

b) did someone hit you?

c) did you hear anything? pop? crack? grinding?

d) did it occur during a game or practice?

e) what was the playing surface like? wet/dry?

f) what type of pain is the patient experiencing ?

where, when, sharp, aching

dull, aching pain is usually indicative of degenerative

intra articular pain.

g) did the knee swell and if so, did the swelling occur fairly rapidly over a 6-8 hour period (ACL) or did it take several days to swell. (meniscus)

2. what functional limitations does the patient have ?

running

cutting

pivoting

twisting

climbing or descending stairs

3. Previous history of injury to that area?

4. Sight/visual evaluation

a) swelling? Is it extra capsular or intra articular ?

intraarticular = ACL, meniscus.

extra-articular = bursae, MCL - LCL ligament tears

b) deformities?

c) discoloration? not a common finding

d) quad tenses (bilateral) - full extension? apprehensive?

5. Palpation evaluation

a) feel for heat - hemarthrosis, blood in the joint is hotter than synovial fluid

b) check patellar movement - medial, lateral, proximal, and distal check for tendencies of patellar apprehension or subluxation

c) check palpable painful sites, ie., medial and lateral joint lines, ligament attachment sites

6. Stress tests

Ligamentous instability

one plane medial

one plane lateral

one plane anteriorly

one plane posteriorly

anterior medial rotary

anterior lateral rotary

posterior medial rotary

posterior lateral rotary

A. check medial and lateral collaterals at 0 and 30 degrees - Valgus Stress

B. Anterior Drawer test for anterior cruciate and posterior drawer for posterior cruciate

check with foot straight

(2) check with the foot turned in and out internal rotation places additional stress on the

posterior lateral capsule. External rotation places additional stress on the medial posterior capsule.

C. Lachman's test - ACL instability

Knee is bent 20-30⁰, the examiner attempts to displace the tibia on the femur. The muscles must be relaxed. Pay special attention to the hamstring muscle group.

Modified Lachman's - the leg is supported by the table. This test is very good if the athlete's leg is too large to hold up or the examiners hands are too small to get a good grip.

Posterior Sag test for posterior cruciate instability. The examiner must look at the anterior tibial borders from the side with the knees bent at 90⁰.

Mc Murray's click test for the integrity of the meniscus. This test is done to "pinch" the menisci against the femur. Internal rotation of the tibia on the femur stresses the posterior medial and the anterior lateral menisci while external rotation stresses the anterior medial menisci and the posterior horn of the lateral menisci.

Probable injured structures in full extension [ positive 2+ laxity ]

MCL

posterior medial capsule

ACL

PCL

medial quad muscles

semimembranosus

Positive findings in full extension are indicative of major ligament disruption

Probable injured structures with the knee flexed to 30 degrees

medial collateral ligament

posterior oblique ligament

posterior cruciate ligament

these injuries are graded 1 2 3 4 from less to worse

some physicians may also used a + or - to differentiate

between lesser or greater degrees of each finding.

Grade 1 = 5 mm of joint opening with good end point

Grade 2 = 5+ to 10 mm of joint opening with good end point

Grade 3 = over 10 mm with spongy end point

Grade 4 = total joint dislocation

Varus adduction test

Probable injured structures in full extension

lateral collateral ligament

posterolateral capsule

arcuate - popliteus complex

biceps femoris tendon

PCL

ACL

lateral head of gastroc

30 degrees of flexion

LCL

posterior lateral capsule

arcuate complex

iliotibial band

biceps femoris tendon

ACL Injury

Positive tests are indicative of ACL disruption with some posterior oblique ligament and arcuate ligament injury also. It may be difficult to test some legs because of there size and muscle mass. Many times, an EUA, evaluation under anesthesia may be necessary to determine the true laxity. A machine, the KT1000 is used by some physicians to measure the tibial displacement of the tibia in relation to the femur.

many plica pathologies mimic meniscal injuries

position the patient in a supine position

move the patella medially while flexing the knee

popping noise or feelings around the patella may indicate a plica.

indicates a laterally subluxating patella.

Q-angle

patellar mis alignment

roughness under the patella - ie: chondromalacia

popping under the patella when the patient does a deep knee bend.

indicative of chondromalacia

patient is laying on the unaffected side

flex the knee to 90 degrees

flex the hip to pt. comfort

extend the leg while applying pressure over the distal I.T. band pain when extending is indicative of positive findings.

little used, measures anterior rotary instabilities

anterior lateral rotary instability

6. Functional tests

a) walking - check gait for heel/toe strike

b) pull heel to butt

c) deep knee bends

d) does the patient complain of the knee giving way?

e) single leg broad jump distance

Meniscal lesions give way to slow speed twisting and bending,

ACL tears have a tendency to feel unstable when the patient is running, cutting, or stopping.

7. Refer to doctor for further examination and possible x-rays