Sign Physical Exam Consent

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okay the next joint exam that we're going to do is the knee and we'll start again with inspection and then palpation and then a range of motion and then specific testing of different structures so the next thing that we the first thing I want to look at with the knee exam is inspection and you want to look for swelling so the first thing that I have them doing is tighten up their quadricep muscle and you'll notice that there is a divot here and a divot here if they have a joint effusion that divot will fill with fluid if it's fluid in the bursa sac the fluid will actually sit here on top of the kneecap and you'll still have your divots and if you squeeze the skin that will hurt the bursa sac so once we've seen where where the swelling might be the next thing that we want to do is have them do active range of motion so we have them extend the knee fully and she can actually hyper extend her ankle a little bit that's near Iker bottom and then we have them flex the knee as far forward as they can with the heel slide always comparing it to the other extremity once we have range of motion the next thing we want to do is identify the structures that may hurt through palpation and I normally start with that the patella and the structures around the patella so first you have your quadriceps tendon and I'll usually have them tighten up their knee and palpate across the quadriceps insertion onto the onto the patella then I'll go to the bottom of the patella and push on the patellar tendon origin on the patella and then follow it down to the insertion on the tibial tuberosity we develop our g-good slaughters disease in a kid if you have pain at the distal patella on an adolescent or a child that is sending larson Johansen syndrome once you've palpated along the patellar tendon and identified possible osgood-schlatters or sending Larson Johansen disease then you want to palpate along the medial and lateral patella palpate along the medial Patel you have the medial retinaculum which attaches the patella to the distal medial femur for stability you can have what's called a medial plica band which is a band of tissue filt like a bowstring when you rub your fingers back and forth then you can feel for tenderness along the lateral patella you can move the patella medially and laterally and feel underneath the patella to see if they're sort underneath where you might get pain with patellofemoral syndrome then you can go down to the area of the proximal tibia where you have the PES anserine bursitis swelling there when they have PES anserine bursitis and that's the attachment of the crows foot for the gracilis Sartorius and semitendinosus tendons next I usually bend their knee to 90 degrees and then you can feel the joint line and I'll start to feel the medial joint line for tenderness either from arthritis or meniscal tear or the lateral joint line and oftentimes if you have a hard time identifying where the joint line is in a very large patient you can at least find that the the fibula and when you find the proximal fibula then you can find the joint line just above it now we've you can also palpate the hamstrings in the back which is hard to show in this video but the semi tendon or the biceps femoris is on attaching to the fibula and the semimembranosus and tendinosis are on the medial aspect and usually when they tighten up their hamstrings you can identify those structures and see if they're sore once we've done observation range of motion palpation then we move to specific testing of different parts of the knee usually again I'll start with the kneecap and I'll start doing some tests for patellofemoral syndrome the first one is Clark's sign where you hold the proximal patella down with some force but not a lot of force if you hold it too hard you'll hurt anybody so you hold it with just a little bit of force then you ask them to fire their quad muscles and you just give them some resistance down on the patella and then I usually have them do that twice the ones that are have bad patellofemoral Center will know that that's going to hurt and they'll be very apprehensive or tentative whereas those that it really doesn't bother we'll just fire right through your fingers the next test is the lateral apprehension test where you put your Fingal fingers medially on the patella and you push laterally as hard as you can and if the patient has had a patellar subluxation or dislocation that eligibly goes laterally and that will cause the Chandeleur sign well they'll jump off the table or really that will really bother them the next structures that we want to palpate or neck structures we want to test is the meniscus which sits in the joint line there's several ways to do this one is that MacMurray's test and now for that test I'll usually put my fingers on the joint line in a c-shaped fashion and then cup the heel with my other hand and then just flex them flex the knee and then internally and externally rotate the tibia then extend the knee and do the doing the same thing and then kind of do it as one big motion and if they say that that causes joint line pain where my fingers are then that can tell you which meniscus may have been injured the next structure that you want to test is the anterior cruciate ligament which keeps the tibia from translating forward you do that by doing the Lockman exam you want to put your top hand across the femur and the quad muscle and the bottom hand across the tibia often times your finger near the tibial tuberosity and then the most important thing is getting them to relax their quadricep muscles and our hip flexors while you're doing this then you have to raise them to about 15 degrees to 30 degrees of knee flexion with your top hand making them comfortable that you're not going to drop their knee then with some downward pressure with the top hand and some upward pressure with the bottom hand you want to stress that ligament and you should feel a nice snap when that ligament becomes taut if you have a soft endpoint or it's a lot looser than the opposite side then that is indicative of an anterior cruciate ligament tear next I'll usually bend the knee again to 90 degrees and feel for a posterior cruciate ligament tear and oftentimes on that if you just put your fingers right down on top of the tibia you should hit the top of the tibia if your fingers do not hit the top of the tibia and go straight down the tibia then the tibia is sitting backwards indicative of a posterior cruciate ligament tear and that's called a sag sign because the tibia is sitting backwards the other way to test that is to sit on their foot put your thumbs on the top of the of the tibia on the joint line put your palms of your hands on the tibia and push backwards and that should not move backwards but a couple of millimeters at the most again always comparing to the opposites uninjured knee and that's a posterior drawer for posterior cruciate ligament stability next another way to test for that ACL is the pivot shift test with that test you want to put your hand your top hand on the lateral joint line your bottom hand cupping the heel and you want to flex the knee while applying a valgus stress immediately to the knee to the knee and what you'll feel is a thunk as the tibia sub Luxe's and reduces back-and-forth at the knee what that's probably the most difficult portion of the knee exam is to get a good pivot shift down the next thing that we want to test is the medial collateral ligament that extends from just above the joint line on the distal femur to below the joint line on the proximal tibia and the best way to test that is to do an exam somewhat like a pivot shift but you cup the heel underneath your hand and put it up in your armpit then you put your hand on their calf you put your top hand on the lateral joint line and you keep their knee fully extended and you apply a valgus stress across the knee joint without rotating the hip with the knee extended the joint should never open if it opens that that means not only do you have an MCL injury but you also have an ACL or a PCL injury next you just want to bend the knee fifteen to thirty degrees and do the exact same valgus stress to the MCL without rotating the hip and on this the easiest thing is to feel not so much the opening of the joint but the closing of the joint as it returns to neutral again comparing it to the opposite knee to test for the lateral collateral ligament which extends from the distal femur to the proximal fibula you do the exact same exam as you did on the medial MCL but you put the foot into your opposite armpit and you put your hand on the medial joint line applying a varus force again first with it extended and the joint should never open an extended position unless you've injured not only the LCL but also the ACL or the PCL and then again with the knee bent about thirty degrees making sure that that patient is comfortable that you're not going to drop their knee and then applying a varus force without rotating the hip to the knee joint and again it's easier to feel the closing than the opening of the joint once you've tested all the major ligaments another good test to do at this point of the exam is the hyperextension test of the knee where you just bend bend the knee and then somewhat in a surprising fashion you let go and let the knee fall into the extended position this exam is it very good for testing what's called fat pad and pigment syndrome the fat pad sits right behind the patellar tendon and often times they'll get aunt your knee pain when that fat pad gets pinched in the joint line similar to biting your cheek while you're chewing your food once we finish examining all the structures individually and we finished with a ligament exam the last thing that we do is test for strength so normally we'll have them bend their knee to 90 degrees and pull their heel to their buttock testing for hamstring strength and then we'll have them push forward against resistance from the hand to test quadricep strength and that really is all of the strength testing for the knee okay for that knee exam the last part of the knee exam that we often do once we get the person off the table is to put them in the middle of the room and have them do some different maneuvers to look for specifically meniscal pathology and the first one we do is called the Thessaly test and basically you have the patient I get their balance and stand on one leg and then bend their knee about thirty degrees and then internally and externally rotate their tibia by rotating and you see if that reproduces their pain along the joint line and if it's a person who has bad balance you can grab their arms and just rotate them like you're dancing with them the next test that we often do is just have the patient duck walk and see if it reproduces their pain along the joint line of their knee and then usually when they're down and they start to have pain wall duck walking we'll have them put their finger in the one spot that hurts to see if the pain that they're actually having is really on their joint line where their is and that would pretty much conclude the exam of the knee that's not done on the table