Evaluation of Anterior Knee Pain

Differential Diagnosis

Most Common

1. Patellofemoral Syndrome

2. Patellar Tendinopathy

3. Fat Pad Impingement

4. Patellofemoral Instability

Less Common

1. Synovial Plica

2. Pre-Patellar Bursitis

3. Quadriceps Tendinopathy

4. Infrapatellar Bursitis

5. Tenoperiostits of the Upper Tibia

6. Stress Fracture of the Patella

7. Osgood-Schlatter Disease

8. Sinding-Larsen-Johanson Syndrome

9. Excesssive lateral pressure sindrome

Not to be Missed

1. Referred pain from the Hip

2. Osteochondritis Dissecans

3. Slipped Capital Femoral Epiphysis

4. Perthes Disease

5. Tumor

History

• Specific nature of the pain

• Aggravating activities

• Clicking / giving way / swelling

• Mechanism of injury

• Presence of the Cinema Sign

• History of surgery

• Previous treatment

Examination

Always remember to examine the joint above (hip) and below (ankle)

Inspection

1. Scars or stretch marks

2. Wasting of muscles: Especially Vastis Medialis

3. Deformity of knee

4. Weight Bearing

Palpation

1. Patella

2. Medial and Lateral Retinaculum

3. Inferior pole of patella

4. Patellar Tendon

5. Infrapatellar fat pad

6. Tibial Tubercle

Motion

Note that range of movement is measured determined actively first, if there is a deficiency, move on to passive range of motion. Any deficits should be measured with a goniometer. Note should be made of discrepence between active and passive movement.

Note should be made of any evidence of locking.

Valgus Stress to test the MCL, this is done in full extension and in 30 degrees of flexion.

Varus Stress to test the LCL, also done in full extension and in 30 degrees of flexion.

Patellar glide may also be tested

Functional tests of motion include squats, step-up, and jump

Muscles

Measurement of muscle strength using the Oxford (MRC) Scale.

1. Flexion

2. Extension

NeuroVascular

1. Check and Grade reflexes

2. Check Pulses

3. Sensation

Special Tests for Effusions

1. Bulge Sign or the varientWipe Test

2. Ballottment test for a floating patella

Special Tests for Meniscal Pathology

1. McMurray Test (note that this test cannot be performed if a large effusion is present).

2. Steinman Test part I and II

3. Helfet Sign

4. Apley compression/distraction test

5. Anderson Test

6. The Sign del Salto also known as the Finocchietto Jump Sign

7. Duck Waddle Test

Note that the accuracy of the McMurray, Steinman, and Apley tests is dependant upon complete relaxation of the patient.

Special Tests for Patellar Dislocation

In Patients who complain of knee giving out, but have no signs of ligamentous instability or meniscal pathology, the diagnosis of patellar instability should be entertained

1. Patellar Apprehension Test

Special Tests for Anterior Cruciate Ligament Stability

1. Lachman Test

2. Anterior Drawer Test

3. Pivot Shift Test and the related Jerk Test

Special Tests for Posterior Cruciate Ligament Stability

1. Posterior Sag

2. Reverse Lachman Test

3. Posterior Drawer Test

Special Tests for Patella-Femoral Disorder

1. Clarke's Sign

2. Waldron's Test for Chondromalacia Patellae

Investigations

1. Plain Films: The Ottawa Knee Rules may help determine the need for a Knee Xray. This may be helpful to detect an Avulsion Fracture or Tibial Plateau fracture. Likewise, osteochondral fractures may be seen.

2. MRI:

3. Ultrasound:

4. Arthroscopy:

5. Examination Under Anesthesia (EUA)

Appendix

Muscular Movement of the Knee

+++ Primary Mover

+ Secondary Mover

Index

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