The Rational Clinical Examination
David L. Simel, Drummond Rennie
Knee Ligaments and Menisci
Daniel H. Solomon, David L. Simel, David W. Bates, Jeffrey N. Katz, Jonathan L. Schaffer
The most common collateral ligament injury results from an abduction and external rotation force...
Topics Discussed:
anterior cruciate ligament, anterior drawer sign, diagnostic process, gait, knee ligament, knee ligament injury, knee meniscus, knee meniscus tears, lachman's test, palpation, posterior cruciate ligament
Excerpt:
"Ten percent to 15% of adults in the community report
knee symptoms, with more than 3.3 million new visits made to physicians
annually.1,2 Overall, knee pain accounts for 3% to
5% of all visits to physicians, and a substantial proportion
results in referrals for diagnostic imaging or specialty care.3 The
history and physical examination can assist the examiner in determining
whether the knee pain is part of a systemic condition or whether
it represents a local musculoskeletal problem. When the knee pain
is part of a local regional musculoskeletal disorder, the clinician
must decide whether the pain represents a torn meniscal or ligamentous structure
and then whether nonoperative or operative intervention is indicated.
Because torn meniscal or ligamentous structures can cause significant pain
and disability, injuries to these structures may require expeditious
repair. The physical examination can aid the primary care clinician
in assessing the likelihood of a torn meniscal or ligamentous structure
and whether a referral will be beneficial.The knee joint is the largest articulation in the body. It is
a modified hinge with an extensive range of motion. The stability
of the joint is provided by the soft tissue structures: the anterior
cruciate ligament (ACL) and the posterior cruciate ligament (PCL),
the medial collateral ligament (MCL) and the lateral collateral
ligament (LCL), the menisci, the capsule, and the muscles (Figure 27-1). The ACL and PCL add stability
to the joint and aid in proprioception. The subcutaneous location in
a weight-bearing extremity, combined with the relatively long lever
arms exerting forces on the joint, renders the knee susceptible
to injury. All of the structures that compose the knee joint synchronously
function through a normal, physiologic range of motion. Knee symptoms
occur when any of these structures are altered, potentially creating interference
with normal knee function.After resolution of acute symptoms, a patient's gait
should be observed. Patients will usually assume a position that
provides them the most comfort. If the patient is seated on the
examination table, the affected knee will be flexed and hanging off
the edge. The quadriceps and calves should be evaluated for atrophy,
often present after ligamentous injuries. The knees should be inspected
for asymmetry that may indicate swelling. An early sign of effusion
is the loss of the peripatellar groove on either side of the patella,
observed best with the patient supine. Also, swelling over the medial
or lateral aspect of the joint should be recorded and may indicate
local inflammation over the collateral ligaments...."
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