Hip & Knee Exam

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Hip Anatomy

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mm of thigh: superficial-

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Front 3

mm of thigh: deep-

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Front 4

first thing on hip exam?

Back 4

observe gait!
then look at superficial landmarks

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mvmts to check on hip exam:

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flexion
extension
internal rotation
external rotation
straight leg raise test

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Ober test:

Back 6

tests IT band

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thomas test:

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looks for hip flexion contractures
-in this pic the woman's left leg would raise up.

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Femoral-Acetabular Impingement (FAI):

Back 8

CAM lesion--bone spur becoming convex

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How do you check for FAI?

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With the FADIR test
-Flexion - ADDuction - Internal Rotation

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FABER?

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*Flexion - ABDuction - External Rotation test
*Useful screening exam for Hip or Sacro-Iliac Pathology
Recently shown to be predictive for detecting FAI

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Trendelenburg Test:

Back 11

checks gluteus medius and minimus (hip abducters)

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Trendelenburg Test: Which Hip Abductors are Affected?

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right side abductors

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Snapping Hip Syndrome: Internal vs. External-

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*internal snapping due to iliopsoas tendon--repetitive stresses like cycling do this
*external snapping due to IT band

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internal snapping hip syndrome:

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*Internal Snapping:
*Iliopsoas Tendon MTJ rubbing over anterior acetabular lip, capsule, or femoral head

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external snapping hip syndrome:

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External Snapping:
Thickened area of the posterior iliotibial band or the leading anterior edge of the gluteus maximus snaps forward over the greater trochanter with flexion of the hip

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Intraarticular (central) snapping hip syndrome:

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Intraarticular (Central) Snapping:

Labral Tear
Femoral Head Fracture (Pipkin)
Loose Bodies
Synovial Chondromatosis
“Joint Mice”

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measure of apparent leg length:

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“Apparent” Leg Length: Xiphoid or Umbilicus to Medial Malleolus

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“True” Leg Length:

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ASIS to Medial Malleolus

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Galeazzi sign:

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*For kids
*In this pic, the kid has DDH on the LEFT hip

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Barlow & Ortolani Tests

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Barlow: attempting to sublux a femoral head that's in the socket

Ortolani: attempting to bring a subluxed femoral head back in.

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This energetic 37yoM complains of right hip pain for 5 months that is interfering with his bicycling. It is worst after sitting in the car for long distance trips and is partially relieved with NSAIDS.

He denies prior injury or surgery to the hip and has not had any prior imaging.

Well-appearing and fit male with no surgical scars, erythema, or lacerations about the hip.

Gait pattern on entrance to exam room smooth and non-antalgic. Mild discomfort apparent when sitting with 90 degrees of hip flexion.

No pain with palpation of ilium or greater trochanter. Mild pain with pressure over the tensor fascia lata.

ROM: 0-130, ER 70, IR 10.

5/5 strength with hip flexion as well as knee and ankle flexion/extension.

FADIR Test Positive with reproduction of symptoms, FABER mild positive

Diagnosis Before Imaging?

Back 21

mild arthritis with an impingement syndrome

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While examining a patient's hip joint, you can hear a "click" and the patient reports pain. Which of the following explanations would NOT define a potential source of the patient's clicking hip (coxa saltans)?

(a) Loose cartilage body within the joint
(b) Irritation of the Iliopsoas tendon anteriorly
(c) Partial tear of the gluteus medius tendon
(d) Irritation of the Iliotibial band laterally
(e) Anterior-Superior labral tear

Correct answer?

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(c) Partial tear of the gluteus medius tendon

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Summary of the entire hip exam:

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Summary of the entire knee exam:

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Front 25

Knee anatomy landmarks:

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Back 26

knee effusion on right side

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Front 28

Mvmts to test in knee exam:

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flexion
extension

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Back 29

knee flexion contracture on pt's left knee.

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Valgus stress test:

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Valgus Stress Test (MCL @ 0)

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Back 31

Valgus Stress Test (MCL @ 30)

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Varus Stress Test:

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LCL @ 30

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Anterior Drawer test:

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ACL @ 90
tests ACL

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Lachman’s Test:

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ACL @ 30
tests ACL

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Stabilized Lachman’s Test

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Similar to Lachman’s for ACL at 30 degrees of knee flexion

Place a bolster or examiner’s knee behind patient’s knee to help muscles relax.

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Posterior Drawer:

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(PCL @ 90)

N.B.: “Reverse” Pivot Shift for PCL Insufficiency:
Flexion to Extension

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Back 37

Tibial Sag Sign
YOU'D SEE THIS IN THE POSTERIOR DRAWER TEST

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MPFL (or Plica) Test:

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Front 39

Patellar Lateral Shift Test:

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Patellar Apprehension Test

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Patellar Ballotment

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Back 42

don't treat the cyst itself usually
it's a response to arthritis, usually

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how do you do meniscal testing?

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McMurray's test.

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Meniscal Testing - McMurray’s

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Back 45

apley's maneuver

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Most sensitive test for meniscal pathology?

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Joint Line Tenderness!

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Miscellaneous meniscal testing:

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Thessaly test (dance)
Duck walk/deep squat
pinch testing
apley's
mcmurray's

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Rating for manual muscle testing:

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Front 49

An athletic 42 yo F complains of knee pain that began during a “Zumba” exercise class two weeks ago. During a twist and bend maneuver, she felt a sharp pain medially and was unable to continue.

It swelled for 3 days then improved, but now she feels a “click” with knee motion. She reports no locking, but felt the knee almost “give way” twice this week while walking upstairs. She nearly fell but held the banister for support.

She denies prior injury or surgery to the knee and has not had any prior imaging.

Well-appearing and fit female with no surgical scars, erythema, effusions, or lacerations about the knee.

Gait pattern on entrance to exam room smooth and non-antalgic. No cane or crutch, but she is wearing a neoprene brace.

Focal Moderate pain with palpation of mid-coronal medial joint line but no pain on lateral or posterior joint lines. MCL and LCL nontender.

ROM: 0-120 with hesitation in deep flexion, Contralateral knee 0-140. No crepitus. 5/5 strength with knee flexion/extension.

Stable to varus and valgus stress at 0 and 30 degrees, stable A/P drawer and Lachman with firm endpoints.

Mildly positive medial McMurray’s with click, negative Apley’s grind, positive pinch in deep flexion, and 20 degree Thessaly test gives reproduction of pain and giving way.

Diagnosis?

Back 49

Torn meniscus!
Probably medial meniscal tear.
Follow up with an MRI.

Front 50

Manual Muscle Testing is graded from 0-5. While examining a patient's knee extension, a Grade of 3 would indicate which of the following:

a) There is no quad muscle contraction whatsoever
b) There is some quad muscle contraction but no corresponding joint motion
c) There is full quad strength against gravity, but weakness with resistance testing
d) There is full quad strength against gravity, but none against resistance
e) There is full quad strength against gravity and resistance

Correct Answer?

Back 50

d) There is full quad strength against gravity, but none against resistance

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Summary points for knee exam:

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The clinician should be able to narrow the differential diagnosis of hip and knee pain down to two to three diagnoses after the history and physical examination.

Imaging studies should ALWAYS be used to confirm the diagnosis. (Especially for CT/MRI testing)

Conventional radiographs should be the initial imaging study ordered.

Many vital structures in the knee can be palpated easily or examined with provocative tests.

A knee effusion usually is associated with internal derangement, and an acute hemarthrosis is almost always associated with cruciate ligament rupture or fracture.