Performance Assessment II: Knee Injuries

Session Plan

• Part 1: Recap of this morning's session
• Part 2: Structuring an MSK objective assessment
• Part 3: Putting the theory into practice

Intended Learning Outcomes

• Understand the structure of an objective MSK assessment.
• Complete an objective assessment of three common knee injuries in athletes.
• Select relevant special tests based on clinical examination.

Knee Injuries

• Meniscal
  • Medial and lateral
  • Fibrocartilaginous
  • Twisting mechanism of injury
• ACL
  • Ligament
  • Resists anterior translation of the tibia
  • Twisting mechanism of injury
• Patellar Tendinopathy
  • Transmits force from quadriceps
  • Commonly caused by over-loading tendon

Subjective Assessment

• Presenting condition and history of presenting condition
  • Why is this person coming to see us?
• Body chart
  • Record location and type of symptoms
• Social history
  • Finding out more about the person's background
• Past medical and drug history
  • Does this person have any other problems?
• Red flag screening
  • Ruling out any potentially sinister pathology

Musculoskeletal (MSK) Assessment

• Two parts:
  • Subjective assessment – asking questions
  • Objective assessment – hands on testing
• Clinical reasoning:
  • Collect information
  • Generate hypothesis
  • Test hypothesis
  • Evaluate hypothesis
  • Diagnose
• Subjective, Objective, Special tests, Diagnosis

Observation

• Starts as soon as you see the patient
  • How they walk into the room
• Static and dynamic observations
  • Standing posture
  • Gait
  • Functional movements
• Consider above and below the knee
  • What is going on at the foot/ ankle/ hip/ spine
• What to look for
  • Antalgic gait, compensatory mechanisms, asymmetry, swelling, redness

Palpation

• Anatomical knowledge is key
  • Need to know what you are palpating
• Areas of tenderness on palpation
  • Report as specific as possible
    • Location
    • How much pressure
• Swelling
  • Sweep test

Knee Effusion Sweep Test

• Grade 0: No wave produced on downstroke
• Trace: Small wave on medial side with downstroke
• 1+: Larger bulge on medial side with downstroke
• 2+: Effusion spontaneously returns to medial side after upstroke (no downstroke necessary)
• 3+: So much fluid that it is not possible to move the effusion out of the medial aspect of the

Range of Movement

• Assess injured and non-injured knee
• Active and passive movements
  • Compare
• Assess all physiological movements
  • Knee
  • Joints above and below
• End feel
  • None – ligament rupture
  • Soft – Swelling
  • Firm – Ligament/ capsular stretch (normal)
  • Hard – Loose body in the joint
• Active knee flexion
  • Supine – bend knee and slide heel
• Active knee extension
  • Supine – quads activation
• Passive knee flexion
  • Same as active but apply overpressure
• Passive knee extension
  • Supine - stabilise the femur and lift heel

Strength

• Assess both sides
• Assess all physiological movements
  • Knee
  • Joints above and below
• MRC scale
  • Grade 0 - 5
• What is causing weakness
  • Pain
  • Deconditioning
  • Neurological

Special Tests

• A clinical test designed to assess the integrity of specific anatomical structures
• Meniscus
  • McMurray’s test
  • Joint line tenderness
  • Thessaly’s test
  • Apley’s (grind) test
• ACL
  • Anterior draw test
  • Lachman’s test
  • Pivot shift test
• Patellar tendinopathy
  • Royal London Hospital Test

Meniscus Special Tests

• Thessaly Test
• Joint Line Tenderness

ACL Special Tests

• Anterior Drawer Test
• Lachman Test

Patellar Tendinopathy Special Tests

• Royal London Hospital Test

Objective Assessment Practice

• Observation
• Range of movement
• Strength testing
• Special tests
  • Thessaly’s test
  • Joint line tenderness test
  • Anterior draw test
  • Lachman’s test
  • Royal London Hospital test