Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

ACSM TPC Part 2 Miami, Florida • February 9, 2013

Examination and Imaging of the Knee and Leg Mary Lloyd Ireland, MD

Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky

ACSM TPC Part 2 • February 9, 2013

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Examination Examination and and Imaging Imaging of of the the Knee Knee and and Leg Leg

Introduction Meniscus Ligament Imaging Cases Conclusions

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Quit

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

A good History and Physical is Key

to a Correct Diagnosis

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Grab Sign

Patellofemoral Disorders

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Fisted Knuckle Sign = ACL Tear

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Alignment

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Miserable Malalignment Syndrome

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Joint line palpation with knee flexed should produce pain if meniscus is torn

Externally rotate tibia for medial meniscus tears, Internally rotate for lateral meniscus tears

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Bounce Home Test

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: Bounce Home

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

McMurray’s Test: Medial Meniscus

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Patient apprehends another lateral patellar dislocation

Positive apprehension test Do the anticipated painful test last

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: McMurray’s Test

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Apley’s Compression Test

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: Apley’s

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

McMurray’s Test: Medial Meniscus

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: Lateral Aspect

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: Ligaments

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Valgus Stress Varus Stress

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Exam and Imaging of the Knee and Leg

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Classification of Knee Instabilities Rotatory, Straight and Combined • Diagnosis:

+1 to +4 by exam

Grade I to IV

• Diagram • Bird’s eye view of tibia • Involved Anatomic Structure • Physical findings • Mechanism and forces • Contact vs. Noncontact • Varus / Valgus, Flexion / Extension • Tibial rotation

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Anterior Instabilities

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Knee Knee Instability Instability

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Posterolateral Instabilities Dia gnosis

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Involved Anatomic Structure

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Mary Lloyd Ireland, MD

Straight Straight Instabilities Instabilities

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Knee Knee Instability Instability

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Anterior Drawer

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: Ligaments

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Exam and Imaging of the Knee and Leg

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Posterior Drawer

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Knee Exam: PCL Exam

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Mary Lloyd Ireland, MD

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Normal Normal Knee Knee Exam: Exam: Reverse Reverse Pivot Pivot Shift, Shift, ER ER Recurvatum Recurvatum

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Radiographs • • • •

Standing 45º PA, bilateral Patellar Views: Merchant or Sunrise Bilateral Lateral 45º Flexion Notch for Osteophytes

• • •

Standardize Your Views for All Physicians Use Goniometer Know Your XRay Technicians

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Osteoarthritis grading systems: • Kellgren and Lawrence • Fairbanks • Joint space narrowing JSM –standing radiographs • Ahlback classification • Numerous studies comparing different classifications—

there is disagreement on the definition and grading of osteoarthritis, as well as poor correlation with patient symptoms and progression of osteoarthritis.

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

References Mazzuca SA, Brandt KD, Schauwecker DS, Buckwalter KA,Katz BP, Meyer JM, et al. Bone scintigraphy is not a better predictor of progression of knee osteoarthritis than Kellgren and Lawrence grade. J Rheumatol 2004;31:329-332. Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med 2011;45:583-588. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg [Am] 1969;51-A:517-26.

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

45 Degree Flexed Weight-Bearing PA View is most sensitive for detecting joint space loss Cole BJ, Harner CD, Degenerative arthritis of the knee in active patients: evaluation and treatment. JAAOS 1999, Nov.-Dec. 7(6):389-402. Dervin GF, Feibel RJ, Rody K, Grabowski J., 3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee. Clin J Sports Med. 2001 Jan;11(1):10-6.

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Exam and Imaging of the Knee and Leg

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Mary Lloyd Ireland, MD

14 YO punter was crushed by defensive line

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Mary Lloyd Ireland, MD

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

16 YO WM Football Athlete Struck from Lateral Side of Knee

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Angular Deformity from 20° Malunion from Proximal tibial growth arrest

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

MRI scan at time of initial injury

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Mary Lloyd Ireland, MD

JamesAaronMatthews.mpg JamesAaronMatthews.mpg

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Anterior opening wedge osteotomy

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Exam and Imaging of the Knee and Leg

Post op: ~ 1 week

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22 weeks

Mary Lloyd Ireland, MD

28 weeks

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

19 19 YO YO Female Female • • •

Collegiate basketball athlete Landed awkwardly in a game PE: ACL Tear, Left knee

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Suspected osteochondral fracture LFC, possible anterior aspect LTP fracture

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Mary Lloyd Ireland, MD

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Exam and Imaging of the Knee and Leg

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42 YO Male: ACL Tear • Injured playing soccer • Beware articular surface injuries

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Technetium Bone Scan LE • Informative for MD + Patient

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Bone Bruise

Does That Predict Development of OA?

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Bone Bruise Patterns • Acute patellar

dislocation • Medial patella anterolateral femoral condyle • No OA from bone bruise, but from articular cartilage injury and mal-tracking

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Bone Bruise Patterns • In soccer, medial tibial plateau bone bruise

no long term risk of OA • In degenerative posterior horn root avulsions, medial tibial bone bruise often seen ? Long-term follow-up for bone bruises needed to determine significance for development of OA

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

What is the significance of Bone Bruises? Unknown. . . • Long term Bone Bruise ≠ OA • In ACL injuries noncontact compartments: • Lateral / acute • Medial / chronic OA • Classification systems for bone bruises

need further development

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Late Results After Meniscectomy Tapper EM, Hoover NW, “Late Results after Meniscectomy,” J Bone Joint Surg Am, 1969 Apr 01;51(3):517-603.

Mayo clinic retrospective review • 1005 patients undergoing meniscectomy • 1936-1956 • 113 examined, 100 questionnaires • Males did better • Best results in bucket-handle resection leaving peripheral rim • Do not leave posterior horn if torn

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Tapper EM, Hoover NW, “Late Results after Meniscectomy,” J Bone Joint Surg Am, 1969 Apr 01;51(3):517-603.

• Discussion by Dr. Don H. O’Donoghue, Oklahoma City, Oklahoma

• I would therefore not accept the conclusion that: • Delay in operation does not affect the ultimate result • Patients under twenty years of age have fewer satisfactory results • Leaving the peripheral ring will give the best results in bucket-handle fractures • Conclusions are not valid based on evidence presented

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Tapper EM, Hoover NW, “Late Results after Meniscectomy,” J Bone Joint Surg Am, 1969 Apr 01;51(3):517-603.

• Discussion by Dr. Don H. O’Donoghue, Oklahoma City, Oklahoma

• I think the authors are to be congratulated on

their efforts to obtain a valid series. As I have indicated, it is extremely difficult to get an uncontaminated series. Probably a study should be initiated, not after operation but before operation, on patients whose surgery would qualify as relatively uncomplicated meniscectomy.

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

History & PE • 55 YO Female • Difficulty walking due to left knee out of • • •

alignment Fell 10 years ago and was told she had meniscal tears PE: Height 5’ 5½”, weight 303: BMI 43 Bilateral Knees: • • •

Diffuse crepitus and pain Mild effusion No calf tenderness

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Mary Lloyd Ireland, MD

Left Knee

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Right Knee

What test would you do next?

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

MRI

Are more tests needed?

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

MRI Scan in the Arthritic Knee After 50 years • Not Helpful for Articular Cartilage • Meniscal Signal Will Usually Be Abnormal

and come to the tibial surface.

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

MRI Scan in the Arthritic Knee After 50 years • Is the root of the Medial Meniscus Avulsed? • What about my Baker’s Cyst? • Think tree - MRI Scan • In a Big Forest – Arthritis

—The Plain Xrays show us the reason for stiffness & pain: Arthritis

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

IMAGING THE ARTHRITIC KNEE • Use goniometer to assure comparable Xrays year to year and for outcome studies • Let the Orthopaedist Order the MRI Scan in

the Arthritic Knee Patient.

• May want DESS or special articular cartilage

sequences. • In most cases MRI scans in patients over age 50 would not change treatment plan. • I don’t need an MRI scan to know what to do arthroscopically! I was scoping knees prior to MRI scans!

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Conclusions • Make the connection between: • Anatomy • Function • History and Physical Exam • In relation to: • Functional disability • Specific diagnosis

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

“The Knee as a Biologic Transmission with an Envelope of Function” Scott Dye. The Knee as a Biologic Transmission with an Envelope of Function. Clin Orthop Rel Res 1996;325:(April): 10-18.

Envelope of Knee Function • Factors: • • • •

Anatomy Kinetics Physiology Treatment

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

The Knee as a Biologic Transmission with an Envelope of Function

A Knee Injury is like a car wreck

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Goal of Treatment of Knee Disorders • • •

Broaden envelope of function Resume activity safely Inform patients of “lowered threshold” of function

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Pyramid Approach to the Management of Osteoarthritis

Creamer P and Hochberg MC, ““Osteoarthritis” Osteoarthritis” (Seminar). Lancet 1997;350:503 -509. 1997;350:503-509.

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Mary Lloyd Ireland, MD

You May Not Have Seen It, But It Has Seen You

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

Right distal femur osteosarcoma

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Exam and Imaging of the Knee and Leg

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S/P Excision Curettage Cementation

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Exam and Imaging of the Knee and Leg

Mary Lloyd Ireland, MD

You Look for What You Know and You Find What You Look For

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Exam and Imaging of the Knee and Leg

The End . . .

Mary Lloyd Ireland, MD

Thank You!

Examination and Imaging of the Knee and Leg Mary Lloyd Ireland, MD

Associate Professor Dept. of Orthopaedic Surgery & Sports Medicine University of Kentucky Lexington, Kentucky

ACSM TPC Part 2 Miami, Florida February 9, 2013

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EXAMINATION AND IMAGING OF THE KNEE AND LEG ACSM TPC II Miami, Florida February 9, 2013

Mary Lloyd Ireland, M.D. UK Healthcare - Orthopaedics & Sports Medicine 601 Perimeter Drive #200 Lexington, KY 40517 (859) 218-3131 Fax: (859) 323-2255 _________________________________________________________________________ BIBLIOGRAPHY

EXAMINATION OF THE KNEE Cole BJ, Harner CD. Degenerative arthritis of the knee in active patients: evaluation and treatment. JAAOS 1999, Nov-Dec 7(6):389402. Creamer P, Hochberg MC. Osteoarthritis (Seminar). Lancet 1997;350:503-509. Harner CD, Hoher J. Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systemic review with meta-analysis. J Orthop Sports Phys Ther 2007;37(9):541-550. Hoppenfeld S. Physical examination of the spine and extremities. Norwalk CT: Appleton-Century Croft, 1976. Hughston JC, Andrews JR, Cross MJ, Moschi A: Classification of knee ligament instabilities: Part I. The medial compartment and cruciate ligaments. J Bone Joint Surg 1976;58A:159-172. Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities: Part II. The lateral compartment. J Bone Joint Surg 1976;58A:173-179. Hughston JC, Barrett GR. Acute anteromedial rotatory instability: Long-term results of surgical repair. J Bone Joint Surg 1983;65A:145-153. Hughston JC, Norwood LA Jr. The posterolateral drawer test and external rotational recurvatum test for posterolateral rotatory instability of the knee. Clin Orthop 1980;147:82-87.

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Kocher MS, Dicanzio J, Zurakowski D, Micheli LJ. Diagnostic performance of clinical examination and selective magnetic resonance imaging in the evaluation of Intraarticular knee disorders in children and adolescents. Am J Sports Med 2001;29(3):292-296. Levenets VN, Lin’ko la V. Functional anatomy, diagnosis and treatment of chronic istability of the knee joint. Klin Khir 1989;12:24-28. Malanga, GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil 2003;84:592. Oiestad BE, Holm I, Engebretsen L, Risberg MA. The association between radiographic knee osteoarthritis and knee symptoms, function and quality of life 10-15 years after anterior cruciate ligament reconstruction. Br J Sports Med 2011;45:583-588. Peeler J et al. Accuracy and reliability of anterior cruciate ligament clinical examination in a multidisciplinary sports medicine setting. Clin J Sport Med 2010;20(2):80-85. Perrin DH. The injured athlete, Philadelphia: Lippincott-Raven, 1999. Riener R et al. Development of a multi-modal virtual human knee joint for education and training in orthopaedics. Stud Health Technol Inform 2001;31:410-416. Solomon DH, Simel DL, Bates BW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001;286(13):1610-1620. Tapper EM, Hoover NW. Late results after meniscectomy. J Bone Joint Surg (Am) 1969;51-A:517-526. Wagemakers HP, Heintjes EM, Boks SS, Berger MY, Verhaar JA, Koes BW, et al. Diagnostic value of history-taking and physical examination for assessing meniscal tears of the knee in general practice. Clin J Sport Med 2008;18(1):24-30. Wood L, Peat G, Wilkie R, Hay E, Thomas E, Sim J. A study of the noninstrumented physical examination of the knee found high observer variability. J Clin Epidemiol 2006;49(5):512-520.

EXAMINATION & IMAGING OF THE KNEE IMAGING OF THE KNEE Abraham AM et al. Reliability and validity of ultrasound imaging of features of knee osteoarthritis in the community. BMC Musculoskelet Disord 2011;12:70. Alioto RJ, Browne JE, Barnthouse CD, Scott AR. The influence of MRI on treatment decisions regarding knee injuries. Am J Knee Surg 1999;12(2):91-7. Anandacoomarasamy A et al. Delayed gadolinium-enhanced magnetic resonance imaging of cartilage: clinical associations in obese adults. J Rheumatol 2009;36(5):1056-1062. Baum T et al. association of magnetic resonance imaging-based knee cartilage T2 measurements and focal knee lesions with knee pain: data from the Osteoarthritis Initiative. Arthritis Care Res (Hoboken) 2012;64(2):248-255. Behairy NH et al. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy. Int Orthop 2009;33(4):961-967. Bolbos RI, Zuo J, Banerjee S, Link TM, Ma CB, Li X, et al. Relationship between trabecular bone structure and articular cartilage morphology and relaxation times in early OA of the knee joint using parallel MRI at 3T. Osteoarthritis Cartilage 2008;16(10): 11501159. Barberie JE, Carson BW, Finnegan M, Wong AD. Oblique sagittal view of the anterior cruciate ligament: comparison of coronal vs. axial planes as localizing sequences. J Magn Reson Imaging 2001;14:203. Bencardino JT, Rosenberg ZS, Brown RR, Hassankhani A, Lustrin ES, Beltran J. Traumatic musculotendinous injuries of the knee: Diagnosis with MRI imaging. Radiographics 2000;20, Spec No.: S103-S120. Bryan S., Weatherburn G, Bungay H, Hatrick C, Salas C, Parry D, Field S, Heatley F. The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint. Health Technol Assess 2001;5(27):1-95. Carballido-Gamio J, Bauer JS, Stahl R, Lee KY, Krause S, Link TM, et al. Inter-subject comparison of MRI knee cartilage thickness. Med Image Anal 2008;12(2):120-135.

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4 EXAMINATION & IMAGING OF THE KNEE Collado P et al. Is ultrasound a validated imaging tool for the diagnosis and management of synovitis in juvenile idiopathic arthritis? A systematic literature review. Arthritis Care Res (Hoboken) 2012;64(7):1011-1019. Davies NH, Niall D, King LJ, Lavelle J, Healy JC. Magnetic resonance imaging of bone bruising in the acutely injured knee—short-term outcome. Clin Radiol 2004;59:439. Davis KW, Tuite MJ. MR imaging of the postoperative meniscus of the knee. Semin Musculoskeletal Radiol 2002;6:35. DeLee JC, Drez DJ. Magnetic resonance imaging of the musculoskeletal system. Operative Technique in Sports Medicine 1995;3(1):71-76. Delle Sedie A et al. Ultrasound imaging for the rheumatologist XXVI. Sonographic assessment of the knee in patients with psoriatic arthritis. Clin Exp Rheumatol 2010;28(2):147-152. Dervin GF, Feibel RJ, Rody K, Grabowski J. 3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee. Clin J Sports Med 2001;Jan;11(1):10-16. De Smet AA, Nathan DH, Graf BK, Haaland BA, Fine JP. Clinical and MRI findings associated with false-positive knee MR diagnoses of medial meniscal tears. AJR Am Roentgenol 2008;191(1):93-99. De Smet AA, Mukherjee R. Clinical, MRI, and arthroscopic findings associated with failure to diagnose a lateral meniscal tear on knee MRI. AJR Am J Roentgenol 2008;190(1):22-26. Domzalski M et al. Risk factors for anterior cruciate ligament injury in skeletally immature patients: analysis of intercondylar notch width using Magnetic Resonance Imaging. Int Orthop 2010;34(5):703-707. Ducher G et al. Ultrasound imaging of the patellar tendon attachment to the tibia during puberty: a 12-month follow-up in tennis players. Scan J Med Sci Sports 2010;20(1):e35-40. Duryea J et al. Comparison of radiographic joint space width with magnetic resonance imaging cartilage morphometry: analysis of longitudinal data from the Osteoarthritis Initiative. Arthritis Care Res (Hoboken) 2010;62(7):932-937. Eckstein F et al. Magnetic resonance imaging-based cartilage loss in painful contralateral knees with and without radiographic joint space narrowing: Data from the Osteoarthritis Initiative. Arthritis Rheum 2009;61(9):1218-1225.

EXAMINATION & IMAGING OF THE KNEE Eckstein F et al. Quantitative MR imaging of cartilage and trabecular bone in osteoarthritis. Radiol Clin North Am 2009;47(4):655673.

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