Diagnostic Tests for Knee sprain
Knee sprain Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Knee sprain:
- Nerve Neuropathy: Related Home Testing:
Knee sprain Diagnosis: Book Excerpts
Tests and diagnosis discussion for Knee sprain:
A thorough
examination is needed to determine the kind and extent of the injury. To
diagnose a collateral ligament injury, the doctor exerts pressure on the
side of the knee to determine the degree of pain and the looseness of
the joint. An MRI is helpful in diagnosing injuries to these
ligaments.
(Source: excerpt from Questions and Answers About Knee Problems: NIAMS)
Diagnostic Tests for Knee sprain: Online Medical Books
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KNEE PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, ASO titer, ANA, CRP, urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joint. X-rays may show a fracture, osteoarthritic changes, and punched-out lesion of gout or chondrocalcinosis (suggesting pseudogout). It is also wise to do a bone survey. Synovial fluid analysis and culture may be done if there is sufficient joint fluid. A trial of therapy can be initiated and may be diagnostic.
If further diagnostic workup needs to be done at this point, it is most cost-effective to refer the patient to a rheumatologist or orthopedic surgeon before ordering MRI or other studies. He may want to do an arthroscopic examination before proceeding with other tests for arthritic conditions. For further workup of knee pain, see
page 279
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
KNEE SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic tests include CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, VDRL test, and x-rays of the involved joint or joints. A bone survey should probably also be done. If there is significant swelling, an arthrocentesis for synovial fluid should be done and the fluid analyzed and cultured. A therapeutic trial may be initiated at this point and can assist in the diagnosis.
If there is still doubt about the diagnosis, referral to a rheumatologist or orthopedic surgeon should be made before ordering MRI or expensive diagnostic tests. An orthopedic surgeon may perform fiberoptic arthroscopy to diagnose the problem. Additional diagnostic tests to order in cases of knee swelling may be found on
page 279
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Knee Pain:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
Both knees, as well as the hip, ankle, and foot on the affected side, should be examined. The knees are inspected for symmetry, signs of quadriceps or calf wasting, and any obvious swellings, discoloration, or pallor. Thigh, knee, calf circumference, and leg length are measured to document any asymmetry. Measurement of the quadriceps or Q angle (normal <15°) is important to evaluate anterior knee pain. Inability to perform full knee flexion and extension will highlight any effusion. Neurovascular supply should also be evaluated.
In nonacute circumstances, the suprapatellar bursa is milked to determine if effusion is present. The patellar apprehension test may detect patellar dislocation; the patellar grind test is used to detect PFS. Evaluation of patellofemoral tracking within the femoral groove also helps make the latter diagnosis as the patella will track laterally in PFS, leading to the characteristic “jockey cap” patella. The knee should be carefully palpated for tenderness of the patellotibial insertion (Osgood-Schlatter’s disease), the body of the infrapatellar tendon (tendinitis), the insertion of the tendon on the patella (Sinding-Larsen-Johannson disease), medial and lateral joint line (potential meniscal pathology), pes anserine bursa (bursitis), or iliotibial band insertion. Plica, a painful, thickened band of exuberant synovium, can also be diagnosed by palpitation of the medial and lateral joint lines.
Ligamentous testing is done next. Test the posterior cruciate ligament through the posterior drawer sign. Use the Lachman test for the anterior cruciate ligament, or, in obese patients, the anterior drawer sign. The medial collateral ligament is tested in zero and 15° of flexion by applying a valgus stress to the knee. The lateral collateral ligament is tested similarly using a varus stress. McMurray’s test may detect a meniscal tear. A duck walk test can also be used to look for a posterior meniscal tear. The patient’s gait is observed, specifically looking for forefoot varus and heel valgus, Morton’s foot deformity, and femoral anteversion, all of which can accentuate valgus stress on the knee and lead to a painful overuse syndrome.
Testing
Most diagnoses can be made without an x-ray study or expensive diagnostic test.
A. Ottawa rules. For acute injuries, the Ottawa knee rules are highly sensitive, but less specific, in determining the need for a plain knee x-ray study in adults (1). This decision rule has not been tested in children. The Ottawa rules recommend an x-ray study if any of the following are found: age 55 years or older, tenderness at the head of the fibula, isolated patellar tenderness, inability to flex the knee to 90°, or inability to bear weight immediately after the trauma (1).
B. Radiographs and procedures. Testing depends on the diagnosis suspected, medicolegal requirements, and response to therapy. Knee films are important when surgical treatment of degenerative arthritis is considered, or if chondrocalcinosis, gout, RA, osteomyelitis, or osteochondritis dissecans should be ruled out. Magnetic resonance imaging (MRI) of the knee is a sensitive and specific test for detecting meniscal or ligament injury; however, it is no better than a consistent history, a positive McMurray’s or Lachman’s test, and medial joint line tenderness (2). MRI is indicated when a patient has a good history for internal derangement and a normal clinical examination, or fails to improve despite adequate conservative therapy. A bone scan is warranted when a stress fracture or cancer is suspected. Computed tomography may define bony pathology and, with arthrography, detect meniscal and ligamentous pathology when an MRI is contraindicated. Duplex ultrasound will rule out a deep venous thrombosis or detect a Baker’s cyst. Arthrocentesis can be used to diagnose gout, pseudogout, or septic arthritis, and to relieve pain and allow corticosteroid instillation. Arthroscopy is helpful when internal derangement is suspected and the probability of arthroscopic treatment is high.
Diagnostic assessment
Clinical information may trigger further immediate diagnostic workup. Hemarthrosis could indicate internal derangement or fracture. Knee pain and a limp in a child with a normal knee examination suggests hip disease (Legg-Calvé-Perthes, slipped femoral capital epiphysis). Bony swelling and night pain suggest tumor; fever and joint swelling, infectious or inflammatory arthritis. A knee effusion with rash suggests gonorrhea, Reiter’s syndrome, or collagen vascular disease.
Of nontraumatic anterior knee pain, 70% is related to patellofemoral syndrome. Meniscal tears can develop in older patients without a trauma history. Knee pain in a growing adolescent is jumper’s knee (patellar tendinitis) or traction apophysitis until proved otherwise.
References
1. Steil IG. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26:405–413.
2. Gelb HJ, Glasgow SG, Sapega AA, Torg JS. Magnetic resonance imaging of knee disorders. Clinical value and cost-effectiveness in a sports medicine practice. Am J Sports Med 1996;24:99–103.>
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Acute Knee Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Careful questioning about the mechanism of injury is most important. Overuse injury or undue stress caused by unbalanced walking is a common source. A sensation of “giving away” on stepping down is a symptom of posterior horn meniscus or anterior cruciate tear. Joint line pain is seen in osteoarthritis, high-grade collateral ligament injury, meniscal tear, and tibial plateau fracture. Pain located medially several centimeters below this is due to anserine bursitis or low-grade medial collateral ligament injury. Anterior knee pain is found in injury to the quadriceps mechanism or large joint effusions. Popliteal pain is usually due to a large knee effusion.
Systematically stress the knee in each direction, looking for pain and/or laxity, comparing with the contralateral side. The range of motion may be limited by effusion, by a meniscal tear, or by a loose body. True locking, with ability to flex but not extend fully, occurs 10 degrees short of full extension. A McMurray maneuver is performed by rotating the tibia on the femur medially with the knee flexed at 90 degrees and then extending the knee, then repeating the process with lateral rotation. A painful “clunk” with medial rotation indicates a lateral meniscus tear, and the same finding with lateral rotation suggests a medial meniscus tear. An anterior drawer sign is elicited as pain and a laxity when the tibia is pulled forward with the knee at 90 degrees, indicating anterior cruciate injury. A Lachman manuver, performed at 15 degrees flexion, is more sensitive. With effusion the hollows of the knee are filled, and a transmitted fluid wave can be elicited.
In acute knee injury, the Ottawa Knee Rule minimizes the number of x-rays without missing a significant fracture. Obtain an x-ray if: (a) age is >54, (b) there is tenderness at the head of the fibula, (c) there is isolated patellar tenderness, (d) there is an inability to flex the knee to 90 degrees, or (e) there is an inability to bear weight immediately and take four steps in the E.R.
Palpable clicks are not necessarily pathologic; they may be caused by the semitendinosus tendon slipping over the medial condyle or the iliotibial band slipping over the lateral condyle.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
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