SPRAIN

Sprain may be diagnosed by:

history of recent injury or chronic overuse
X-ray to rule out fractures
stress radiography to visualize the injury in motion
arthroscopy
arthrography.
STRAIN
Diagnosis of strain may include:
history of a recent injury or chronic overuse
X-ray to rule out fracture
stress radiography to visualize the injury in motion
biopsy showing muscle regeneration and connective tissue repair (rarely
done).

KNEE LIGAMENT SPECIAL TEST

MEDIAL
Valgus stress test at 30 degrees and 0 degrees:
Patient is supine and relaxed, thigh supported on table. Examiner applies
valgus force at foot, while using other hand as fulcrum along lateral side of
joint. Watch and feel for medial joint line opening. Perform fi rst with knee
flexed 30 degrees, then with maximum possible extension or hyperextension
(
Anterior drawer test with external rotation of tibia:
Patient is supine and relaxed, hip flexed to 45 degrees and knee to 90
degrees. Externally rotate foot 30 degrees, then pin foot to table with
examiners thigh. Grasp proximal tibia with both hands and pull toward
examiner. Positive test is excessive anterior rotation of medial tibial condyle
(see Fig. 49-3 ).
Medial Ligaments Examination:
Positive valgus stress test at 30 degrees fl exion. Compare with opposite
knee. An injured medial collateral ligament (MCL) along with disrupted ACL or
PCL will result in more gap occurring with a valgus stress test, particularly
noticeable when knee is tested in extension. Frequently, but not always,
positive anterior drawer sign results with tibia in external rotation. Medial
tibial condyle rotates anteriorly.
Imaging:
Abduction stress fi lm may be used to distinguish ligament injury from
epiphyseal fracture in skeletally immature athletes.
Fracture opens at growth plate.
Ligament tear opens at joint line. Do in 20 to 30 degrees of fl exion.
 LATERAL
Varus stress test at 30 degrees and 0 degrees:
Patient is in same position as for abduction stress test. Reverse hand position
so that one hand applies varus stress, while opposite hand acts as fulcrum
along medial side of joint. Watch and feel for lateral joint line opening.
Perform at 30 degrees of fl exion and then at full possible extension or
hyperextension
External rotation recurvatum test:
Patient is supine and relaxed. Lift entire lower extremity by fi rst toe. Observe
for excessive recurvatum and external rotation of proximal tibia (tibial
tuberosity) and apparent varus deformity of knee. Indicates posterolateral
corner injury.
Posterolateral drawer test:
Same position as for anterior drawer test with external rotation of tibia.
Examiners hands push posteriorly on proximal tibia. Positive test is
excessive posterior rotation of lateral tibial condyle
Prone external rotation test (Dial test):
The patient is prone with knees together and the feet are externally rotated
at 30 degrees of knee fl exion and then at 90 degrees. The external rotation
of the foot relative to the thigh is compared with the contralateral side. Test
is positive if there is more than 10 degrees of rotation of affected side
compared to normal side. If asymmetry is present only at 30 degrees than
isolated posterolateral corner injury is likely. If asymmetry is present at both
30 degrees and 90 degrees then a combined injury to posterior cruciate
ligament (PCL) and posterolateral corner is present
Reverse pivot shift test:
Performed with tibia in external rotation rather than internal rotation. With
knee fl exed 90 degrees, lateral tibial condyle is subluxed posteriorly. With
further knee extension, tibia reduces with detectable clunk. (See later
discussion of pivot shift test.)
Lateral Ligaments Examination:
Compare with opposite knee. In acute case, may be increased varus stress
test at 30 degrees of fl exion and positive posterolateral drawer sign; chronic
case shows positive reverse pivot shift test and external rotation recurvatum
test. External rotation recurvatum may also be apparent on standing, giving
increased varus appearance to knee.
Imaging:
Lateral capsular sign shows avulsion of midportion of lateral capsular
ligament with small fragment of proximal lateral tibia.
Associated with high incidence of anterior cruciate tear and indicates
anterolateral instability .
Arcuate sign shows avulsion of proximal fi bula with posterolateral ligament
complex. Indicates posterolateral instability.

ANTERIOR CRUCIATE LIGAMENT (ACL)

Lachman test:
 Patient is supine and relaxed. Examiner grasps distal femur with one hand,
while other hand grasps proximal tibia. Knee fl exed to approximately 15 to
20 degrees. Apply anterior force to proximal tibia. Positive test is excessive
anterior translation of tibia beneath femur and lack of fi rm endpoint
Anterior drawer test in neutral rotation:
Same position as for anterior drawer with external rotation of tibia, except
that foot and tibia are in neutral rotation. Anterior pull is applied to proximal
tibia. Positive test is anterior translation of both tibial condyles from beneath
femur (see Fig. 49-3 ). Note: This test is infl uenced by structures other than
anterior cruciate ligament. Do not rely on this test for diagnosis of ACL tear.
Pivot shift test and jerk test:
Patient is supine and relaxed. Begin with knee fully extended (pivot shift test)
or fl exed to 90 degrees (jerk test). Foot and tibia internally rotated. Valgus
applied at knee. Knee progressively fl exed (pivot shift test) or extended (jerk
test). At approximately 30 degrees, watch and feel for anterior subluxation of
lateral tibial condyle. Tibia suddenly reduces with further fl exion (pivot shift
test) or extension (jerk test) .
Anterior Cruciate Ligament (ACL) Examination:
Acute, large hemarthrosis, positive Lachman test. Chronic, positive Lachman
test, positive pivot shift test or jerk test. Perhaps positive anterior drawer
sign, but not reliable. Do not rely on anterior drawer sign.

1-history2-magnetic resonance imaging MRI or X-ray or Arthrograms

X-rays. Although they will not show any injury to your anterior cruciate
ligament, x-rays can show whether the injury is.associated with a broken
bone
Magnetic resonance imaging (MRI) scan. This study creates better images of
soft tissues like the anterior cruciate ligament. However, an MRI is usually
not required to makethe diagnosis of a torn ACL Arthrograms: These studies
have generally been replaced by MRI.
Arthrograms are mostly of historical interest, having occasionally been used
by physicians to diagnose ACL ruptures; they must be performed by a
radiologist who is highly skilled in double-contrast arthrography
Checking your knees for stability, strength, range of movement, swelling,
and tendernes
special test
Imaging:
Lateral capsular sign; avulsion of tibial spine may be seen in young patients.
Magnetic resonance imaging (MRI) useful in acute injury to confirm diagnosis
and evaluate for injuries to other structures; reported accuracy rates as high
as 95% in detecting ACL tears.

POSTERIOR CRUCIATE LIGAMENT (PCL)

1-history
 2-magnetic resonance imaging MRI or X-ray or Arthroscopy

X-rays. Although they will not show any injury to your posterior cruciate
ligament, X-rays can show whether the ligament tore off a piece of bone
when it was injured. Thisis called an avulsion fracture

MRI. This study creates better images of soft tissues likethe posterior
cruciate ligament

Checking your knees for stability, strength, range ofmovement swelling, and
tendernes and posrerior sag

special test

Posterior drawer test: Same position as for anterior drawer test in neutral
rotation. Posterior force is applied to proximal tibia. Positive test is straight
posterior displacement of both tibial condyles. Caution: Make sure of neutral
position as starting point. Compare position of tibia relative to femur with
normal knee. It is easy to start from posteriorly displaced position and
interpret reduction to neutral as positive anterior drawer sign rather than
starting at neutral and interpreting as positive posterior drawer sign.
The degree of posterior instability can be graded as follows:
Gr I: 5 mm posterior displacement
Gr II: 510 mm posterior displacement
Gr III: >10 mm of posterior displacement
Gravity or sag test:
Patient is supine and relaxed. Flex hips to 45 degrees and knees to 90
degrees with feet fl at on table. With quadriceps relaxed, observe from lateral
side for posterior displacement of one tibial tuberosity compared to the
other. Then fl ex hips to 90 degrees, support both legs by ankles and feet,
and observe again.
Valgus or varus stress test at 0 degrees:
As described for abduction and adduction stress tests at 30 degrees and 0
degrees. Positive test in full extension in acute case is often due to posterior
cruciate ligament rupture in addition to injury to associated collateral
ligaments
Posterior Cruciate Ligament (PCL) Examination:
Acute, if produced by varus or valgus mechanism, may fi nd abduction or
adduction stress test positive in full extension.
If produced by blow to anterior tibia, posterior drawer sign may be positive.
Chronic, rely on posterior drawer sign and gravity test
Imaging:
Cross-table lateral view x-rays may show sag of tibia compared to opposite
side; may accentuate by doing posterior drawer sign while taking cross-table
lateral view. May see bony avulsion with tibial attachment of the posterior
cruciate ligament. MRI shows posterior cruciate well and may help confi rm
diagnosis and evaluate for other injuries
 patellar tendon

1-history
2-Imaging Tests -magnetic resonance imaging MRI orX-ray or
Ultrasonography
X-rays. The kneecap moves out of place when the patellar tendon tears. This
is often very obvious on a sideways x-ray view of the knee. Complete tears
canoften be identified with these x-rays alone
MRI. This scan creates better images of soft tissues like the patellar tendon.
The MRI can show the amount of tendon torn and the location of the tear.
Sometimes, an MRI is required to rule out a different injury that hassimilar
symptoms
Ultrasound . is extensively used as a diagnostic tool before surgery on acute
traumatic tears of the patellartendon and quadriceps tendons
3-Checking your knees for stability, strength, range ofmovement, swelling,
and tenderness

Quadriceps Tendon
1-history
2-Imaging Tests -magnetic resonance imaging MRI orX-ray or
Ultrasonography
X-rays. The kneecap moves out of place when the quadriceps tendon tears.
This is often very obvious on a sideways x-ray view of the knee. Complete
tears canoften be identified with these x-rays alone
MRI. This scan creates better images of soft tissues like the quadriceps
tendon. The MRI can show the amount of tendon torn and the location of the
tear. Sometimes, an MRI is required to rule out a different injury that
hassimilar symptoms
Ultrasound . is extensively used as a diagnostic tool before surgery on acute
traumatic tears of the patellartendon and quadriceps tendons
3-Checking your knees for stability, strength, range of