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In the evaluation process of a knee injury, the examiner will begin by obtaining a detailed history of what happened, what structures might be involved, the severity of the injury, previous injuries that have occurred, and the physical, mental, and psychological sensations they are experiencing, all to gain a better understanding of the injury at hand. The patient's detailed description of the mechanism of injury will gauge the process in determining the individual’s injury and the steps that should be taken to further evaluate the injury and assess its appropriate treatment. An accurate and thorough patient history will consistently provide the examiner with the proper diagnosis.
Site of Injury
A key component in examining an injury is to determine the specific point(s) at which the source of pain arises, which can be found by asking questions such as:
· If you could point to a specific point on your knee with one finger, where would the most pain be radiating from?
· What type of structure do you feel is injured--a muscle, ligament, bone?
Mechanism of Injury (MOI)
The patient's description of the mechanism of injury allows the examiner to better understand the source of the injury. This is extremely important and usually helps narrow the type of injury that has taken place, and many of the following questions should be inquired:
· What were you doing (playing soccer, running, quick change in direction, etc.) when the injury first occurred?
· What type of surface were you on when this took place?
· What type of feeling was it, a pop, a crack, sharp, locking up, did your knee seem to come out of joint etc.?
· If you were jumping, how did you land? How was your body oriented?
· What kind of footwear were you wearing? Are they different from the ones you usually wear? How old are they? Do you wear orthotics as well?
Previous Injuries
It is important to be aware of the patient's previous injuries such as scars, deformities, or weaknesses which could lead to a misdiagnosis if not known. For example, if the individual has previously torn a ligament, it will help in evaluating the injury due to differences when compared to an uninjured structure. Other important considerations of prior injuries are the MOI, when they returned to play, and how the injury was previously treated. Many times athletes return to play too early and re-injure themselves because the injury was not fully rehabilitated which can lead to a more severe injury and/or recovery time. Also, be aware of congenital or pre-existing knee conditions that may have attributed to the current injury. Some essential questions to ask are:
· Have you previously injured this structure?
· If so, how long ago, and how was it treated?
· Do you have any pre-existing or congenital conditions of the knee?
Sensations
Asking the individual about their initial and current sensations is vital to the evaluation. This feedback allows the examiner to gain an image of what structures are injured locally, regionally, and sometimes even systemically. Some key questions might include:
· What different sensations do you have in the area?
· Do you feel tingling or numbness anywhere now or when it first happened?
· If pain is present, can you describe the type such as being dull or sharp? And when did the pain begin? Before, after or during the activity.
· On a scale of 1-10, 10 correlating with slamming your hand in a car door, what numerical intensity of pain are you currently experiencing?
Initial Care
The initial care of the patient, prior to an evaluation by a trainer or physician, such as icing, activity level, intake of aspirin or any other pharmaceutical drug, will allow the examiner to know the progress and further treatment of the injury. This is significant to know if further injury occurred after the initial injury, or if they rested and iced properly to prevent further injury.
· Right after the injury did you stop what you were doing, or did you continue to push through the pain?
· Did you ice the injury, if so how often?
· How has your injury changed in feeling and appearance since you first injured the area?
Medication
Knowing the patient's current and previous medication(s) will give the examiner key information for treatment if any prescription(s) in the future is necessary. When medication is prescribed to a patient current medications are very important to be aware of since certain drug interactions can have negative effects.
The next step to a thorough examination of a knee injury is observation. When making observations of the knee, it is important to be aware of deformities, scars from previous surgeries or injuries, lacerations, discoloration, and localized swelling to get an idea of the magnitude of force and the mechanism of injury rather then a previous injury. With any signs of injury, it is essential to observe the contralateral limb to compare differences.
*All signs and symptoms are relative to location and type of injury which may range from moderate to severe depending on the seriousness of injury*
Swelling
The time of swelling after an injury is a key element in determining the result of injury.
(Source:www.arthritisusa.net/
· Effusion: Excessive accumulation of fluid within the knee joint.
*Immediate (0-2hrs.) indicates rupture of a ligament (most commonly ACL), or fracture.
*Slow (24-36hrs.) indicates meniscal injury or ligament sprain (this is consistent with recurrence of injury).
· Edema: Excessive accumulation of fluid within the cell bodies.
· Baker’s Cyst: Excess joint fluid protruding on the posterior aspect of the knee.
· Bursitis: Fluid filled sacs that help to lessen friction during joint movement become inflamed and/or infected. Common areas of Bursitis include: superior/inferior to the kneecap and the inferior-medial side of the knee. Visual symptoms include swelling, as a result of fluid accumulation, redness about the knee.
Abrasion
Damage to the superficial region of the skin. Cuts and scrapes can be a clear indicator to the location of injury deep to the skin.
· Infection: Foreign microorganisms embedded at the site of abrasion that feed off of host cells. Problems associated with infection can include gangrene, chronic abrasion, loss of limb. Symptoms include: Redness, Pus, Swelling, and Odor.
· Bleeding: Depending on the severity of the cut, continual blood loss can result from deep tissue or arteriole laceration (Popliteal, Circumflex Femoral, Tibial, and Lateral Inferior Genicular arteries).
Dislocation
Occurs when the Tibia, Fibula, Femur, or Patella bones that make up the knee are displaced due to injury of their respective ligaments. Knee dislocation requires injury to at least 3 of the 4 main ligaments. There are 5 possible types of knee dislocations:
Anterior: Tear to the posterior ligament (hyperextension). Visually the distal Femur is found posterior to the proximal Tibia or Fibula.
Posterior: The proximal Tibia or Fibula is found posterior to the distal Femur.
Lateral: Results from Varus force to the knee. Visually the knee bends laterally.
(Source: http://www.fighttimes.com/magazine/magazine.asp?article=565)
Medial: Results from Valgus force to the knee. Visually the knee bends medially, as seen below:
Rotational: Results from the body rotating while the foot remains planted.
Fracture
Crack or break in the bone that. It is hard to observe stress fractures, so this evaluation will be done next with palpation.
Compound: A fracture that breaks the seal of the skin.
Discoloration
Coloring of the skin is a great indicator of tissue death, and injured structures. This will also help the examiner see where the injury is at in its healing process, since different colors of bruising indicate different stages of healing. Bruising will many times be accompanied with swelling and pain, which all will effect palpating the area and conducting special tests.
Palpation, the examination using the sense of touch, allows the examiner to obtain a complete and in-depth inspection of the knee injury. This will assist the examiner in ruling out certain injuries to determine the correct diagnosis. While the patient’s knee is in a flexed position, the examiner will carefully inspect for pain, warmth, effusion, and point tenderness. The most important aspect of palpating a structure of the knee is to compare bilaterally to ensure symmetry. The examiner should begin the assessment distally, working superiorly to the injury site. This should be accomplished by using a soft touch to start with to gain the trust of the patient, and slowly become more firm to properly assess the structures.
Key elements to note:
· The temperature of the leg (warmth)
· Tenderness expressed by the patient in specific areas
· Abnormalities in structures, making sure to examine all surrounding structures (ligaments, bones, tendons, etc.)
· Feeling of crepitis, locking, popping
· Pain with compression
· The presence of a pulse (dorsalis pedis, or in the region of the popliteal fossa)
(Source: http://www.sportsdoc.umn.edu/Clinical_Folder/Knee_Folder/Knee_Exam/tenderness%20main.htm)
Structures within the Knee
All of the following structures are aspects of the knee which guide the examiner through the palpation process. The knee can be divided into four different compartments, anterior, medial, lateral, and posterior.
Click on the individual compartments of the knee to view images:
Patella: begin palpating the patella superiorly, at the quadriceps insertion. Take note of any tenderness as this is done. Begin to move inferiorly, and then both medially and laterally along the borders of the patella. Make sure there is proper alignment of the patella, as it should be able to move freely in the fremoral trochlea.
Patellar Tendon: Begin palpating the tendon at its insertion at the tibial tuberosity just inferior to the patella. As the patient moves their knee through range of motion, feel for any crepitus which can indicate the presence of patellar tendonitis.
Tibial Tuberosity: This is the attachment site to the patellar tendon, and can be felt as a smooth, rounded landmark that slightly protrudes just below the patella.
Quadriceps Tendon: This tendon attaches to the superior aspect of the patella and continues to stretch up the thigh of the leg.Sartorius Muscle: The sartorius can be palpated along its path on the anterior aspect of the thigh from the anterior superior iliac spine to its insertion as a part of the pes anserine tendon.
Medial Joint line: With the knee at 45 degrees of flexion, the joint lines of the knee are best seen. This can easily be felt with palpation, as it is an indentation formed between the femur and tibial plateau. Palpate this indentation noting any abnormalities, crepitus, or main inflicted to the patient. This can indicate injuries to the medial meniscus, the joint capsule, or ligament damage.
Medial Meniscus: The medial meniscus can be palpated deep to the medial joint line. Once at the joint line the examiner will use pressure to feel if there are any irregularities.
Medial Collateral Ligament (MCL): The origin of this ligament is found on the medial femoral condyle, and stretches to the medial tibial flare of the tibia, its insertion site. The MCL will partially cover the medial joint line.
Medial Tibial Plateau: This plateau sits inferior to the medial joint line and can easily be felt when palpating.
Medial femoral condyle: These structures can be seen on the medial aspect and superior to the medial joint line. They can easily be exposed by putting the patient's knee into
90 degrees of flexion. These structures will be tender when injuries are caused by rotation or over-loading.
Pes Anserine Tendon and Bursa: The Pes Anserine tendon composes of the Gracilis, Sartorius, and Semitendinosus muscles. Their attachment sites can be found at the tibial flare, where the tendon can be palpated. The Bursa can be found just medial to the Tibial Tuberosity, which will become a problem if the patient had a direct blow to the are, a
it will become inflamed.
Gracilis Muscle: The gracilis is located medially and immediately anterior to the semitendinosus tendon. It is thin and rope-like.
Lateral Joint Line: With the knee in 45 degrees of flexion, the lateral joint line can be found. Pain found at the joint line will often times indicate a meniscal tear or injury.
Lateral Meniscus: Can be found in the lateral joint line. It will easy to tell of a tear to this ligament when palpating due to a protrusion anteriorly to the lateral joint line.
Lateral Collateral Ligament (LCL): With the knee in 90 degrees of flexion while also externally rotating and abducting the hip, the LCL will be able to be easily palpated. The
LCL is much easier to find then the MCL, as it is not a structure of the joint capsule. The LCL is much easier to identify from its insertion to origin.
Lateral Tibial Plateau - At the inferior pull site of the patella, draw lateral and inferior with the thumb until reaching the joint line, continue down until stopped by bony
prominence.
Head of Fibula: The fibular head can be found slightly posterior and inferior to the lateral joint line. The LCL and biceps femoris tendon come off of the head of the fibula.
Iliotibial Band: Located anterior to the biceps femoris and lateral to the tibial tuberosity. The IT band can easily be identified when the knee is in 30 degrees of resisted flexion. This is a long band that runs a large portion of the thigh. Feeling for sensitivity as you run your hand across this band should be noted, which can show signs of iliotibial band syndrome.
Popliteus muscle: This muscle can be found posterior to the LCL, superior to the joint line.
Popiteal fossa: When palpating this fossa feel for increased fluid within the fossa when comparing bilaterally. Trauma to this area can cause many problems, one being the occlusion of nerves in the area. It is important to recognize this fluid accumulation and evaluate its severity.
Biceps Femoris: Lateral aspect of the posterior compartment of the knee is where you can find the biceps femoris.
Semimembranosus: Located on the medial aspect of the hamstrings. Insertion can be found at the ischial tuberosity. The semimembranosus is the larger tendon on the medial side and can be palpated more easily with flexion of the knee.
Semitendinosis: Also found on the medial aspect of the hamstrings muscle group. In all the hamstrings make sure to note any tenderness, defomities in muscle structure or spasming. The semitendinosus is slightly smaller than the semimembransosus and also slightly more medial. It can also be palpated more easily with flexion of the knee.
Gastrocnemius: Found inferiorly to the popliteal fossa. The gastrocnemius muscle has two heads, one medial and the other lateral.
As stated before, it is extremely important to compare the non-injured structure of the contralateral knee to the injured knee to get a strong basis of what the area is usually suppose to look like and feel like. This is another opportunity to ask more questions, incase the patient has prior injuries to their un-injured knee and there appears to be some irregularities. To correctly asses the knee structures, a strong background in the anatomy of the knee and leg is vital to the success of proper diagnosis.
References
* Hutchens, Mark M.D. Walter L. Calmbach M.D., Evaluation of Patients Presenting with Knee Pain:
* Kauffman, Jeffrey M.D. MedicalPlus Medical Encyclopedia: Knee Cap Dislocation. 2006. http://www.nlm.nih.gov/medlineplus/ency/article/001070.htm.
* Starkey C, Ryan J. Evaluation of Orthopedic and Athletic Injuries 2nd Ed. F.A. Davis Company 2002.
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