Review Note

Examination:

• ACL
• Knee swelling (due to hemarthrosis), pain, & instability.
• Positive Lachman test
  • Patient lies on back with knee in ~20° angle.
  • The lower leg is grasped & pulled ventrally à increased movability of tibia.
• Positive anterior drawer test
  • Patient lies on back with knee in ~90° angle.
  • Lower leg is pulled forwards à increased gliding of tibia forwards.
• Positive pivot test
• Patient lies on back with hip flexed at ~20° angle.
• Lower leg is internally rotated while simultaneously applying axial compression cranially & valgus stress à knee is flexed to ~40° angle à ventral subluxation of tibia.

• PCL
• Initially vague symptoms: minimal or absent posterior knee pain, swelling, decreased functional ROM.
• Positive posterior drawer test
  • Patient lies on back with knee in ~90° angle.
  • Lower leg is pushed backwards à increased posterior gliding of tibia.
• Positive posterior sag sign
• Patient lies on back with hip & knee at 90° angles.
• Heel is held by examiner à tibia glides backwards forming a dent on the anterior tibial margin & lower end of patella (exacerbated when patient presses heel down against examiner's hand).

• MCL & LCL
• Pain, swelling, bruising, deformity, knee joint instability.
• MCL
• Medial joint line tenderness.
• Valgus stress test
• Patient lies on back with either the knee extended or in 20-30° flexion.
• One hand placed on the lateral side of proximal tibia & other hand placed on the medial part of distal tibia right above the ankle joint.
• Press proximal tibia medially while simultaneously pressing the distal tibia laterally à widening of medial joint space indicates MCL injury.

• LCL
• Lateral joint line tenderness.
• Varus stress test
• Patient lies on back with either the knee extended or in 20-30° flexion.
• One hand placed on the medial side of proximal tibia & other hand placed on the lateral part of distal tibia right above the ankle joint.
• Press proximal tibia laterally while simultaneously pressing the distal tibia medially à widening of lateral joint space indicates LCL injury.

• Meniscus Tears
  • Joint line tenderness (medial or lateral) – most sensitive physical examination finding.
  • Restricted knee extension.
  • Intermittent joint effusion.
  • McMurray’s test
    • Medial
      • Place knee in flexion & palpate medial joint line.
      • External rotation & valgus while extending the knee.
    • Lateral
      • Place knee in flexion & palpate lateral joint line.
      • Internal rotation & varus while extending the knee.
    • Presence of pop or pain at joint line indicates meniscus injury.
  • Thessaly test
    • Patient stands at 20° knee flexion à twists with knee into external & internal rotation à pain or clicking indicates meniscus injury.
    • May also feel as if the knee is locking.
  • Appley grind test
    • Patient lies on stomach with knee in 90° flexion.
    • Examiner gently holds thigh in place with own knee while applying downward pressure on the knee joint with both hands à alternately apply internal & external rotation to the knee joint.
    • Medial pain on external rotation à medial meniscus damage.
    • Lateral pain on internal rotation à lateral meniscus damage.
  • Steinman test
    • Similar to Appley grind test, but patient lies on back with both hip & knee flexed.
    • Examiner fixes the knee with one hand & applies internal & external rotation to the lower leg.
    • Medial pain on external rotation à medial meniscus damage.
    • Lateral pain on internal rotation à lateral meniscus damage.
• MRI can be done as a confirmatory test.

Treatment:

• Ligament Tears
  • Conservative Treatment
    • Indications – mild knee instability, less physically demanding occupation, premorbid inactivity.
    • Analgesia.
    • Physiotherapy.
    • Maintaining good quadriceps muscle strength.
    • Bracing, orthoses.
  • Arthroscopic Surgery
    • Indications – multiligament injury, severe knee instability, competitive athletes.
• Meniscus Tears
  • Conservative
    • Indications – 1st line for degenerative tears.
    • Rest, NSAIDs, physiotherapy, maintaining good quadriceps strength.
  • Surgery
    • Indications – persistent disabling pain, complex tears, functional limitations.
    • Partial meniscectomy.
    • Meniscal repair.
    • Meniscal transplantation.
    • Total meniscectomy (not done anymore).