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Examination of the Knee

4 min read

Examination of the Knee

Prof. Mamoun Kremli

Orthopedic Examination

The system to use:

  • Look
  • Feel
  • Move
  • Special tests

Summary

Knee Examination Systematic Approach

  • Look

    • General → on patient
    • General → local (knee, thigh, leg): Position, Major deformity, swelling, Extra
    • Anatomic local

  • Feel

    • Tenderness, Temperature, Anatomical

  • Move

    • Active, Passive

  • Special Tests

    • Patella-related
    • Effusion
    • Ligaments
      • Collaterals
      • Cruciate
    • Menisci
    • Gait – walking

Look

General → on patient

  • Proper exposure
    • The patient should be in either a gown or shorts
    • Rolled up pant legs do not provide good exposure!

  • Position examples:

    • Sitting comfortably on edge of couch, with knees flexed 90°

    • Sitting, in pain, with both hands around flexed knee
  • Sitting on a wheelchair, with knee extended on a board

General → local (knee, thigh, leg)

  • Position and alignment

    • Flexion / Extension

  • Major deformity and swelling
    • Varus / Valgus - Best assessed in standing
    • Swelling / Masses
  • Extra equipment and devices
    • Cast, splint, dressing
  • Skin traction, skeletal traction
  • Orthotics
    • AFO (Ankle-Foot Orthosis)
    • KAFO (Knee-Ankle-Foot Orthosis)
    • HKAFO (Hip-Knee-Ankle-Foot Orthosis)

Anatomic local

  • Systematic examination:
    • Skin: swelling, scars, color, hair, dryness
    • Subcutaneous: lymph nodes, veins, nerves, tendons
    • Muscles: bulk, wasting, twitches
    • Bones: landmarks, swelling, angulation, deformity
    • Joints: position, swelling, redness

(Do not forget the posterior aspect!) (All patients have a posterior aspect!)

CC

  • Visual examples:

  • Posterior aspect

Feel

Tenderness

  • Generalized: to start with
  • Specific points:
    • Quadriceps muscle
    • Patella
    • Patellar tendon
    • Tibial tuberosity
    • Joint lines: medial/lateral
    • Collateral ligaments
    • Head of Fibula
    • Popliteal fossa
    • Hamstrings

Knee - Medial Structures

  • Tibial Tuberosity
  • Joint Line
  • Medial Tibial Condyle
  • Patella
  • Medial Femoral Condyle
  • Joint Space - The space between the Medial Femoral Condyle and Medial Tibial Condyle
  • Medial Collateral Ligament (MCL)

Knee - Lateral Structures

  • Quadriceps
  • Patella
  • Tibial Tuberosity
  • Head of Fibula
  • Lateral Collateral Ligament (LCL)
  • Lateral joint line

Temperature

  • Compare distal/proximal and right/left sides

Anatomic Examination

  • Skin: dryness, hyper/hyposthesia, scars
  • Subcutaneous: lymph nodes, nerves, vessels, tendons, nodules
  • Muscle (Quadriceps): tone, bulk, twitches, gaps, tenderness (measure girth if needed)

  • Bone: landmarks (Patella, Tibial Tuberosity, head of Fibula) tenderness, mass, crepitus

  • Joint lines: anterior, medial, lateral

  • Joint assessment: swelling, effusion, crepitation, synovial thickening, joint line tenderness

Move

  • Active Vs. Passive
    • Better to start with active
  • Need to assess the range of motion
    • painless / painful
    • Extension: 0° → Flexion: 140°
    • →
  • Describe loss of degrees of extension
    • Example: “lacks 5 degrees of extension”
  • Locking:
    • Patient unable to fully extend or flex knee due to a mechanical blockage in the knee (i.e., loose body, bucket-handle meniscus tear)

  • Normal range:
    • Flexion / Extension
  • Abnormal range:
    • Anything less
    • Increased
    • Within normal direction:
      • hyper-extension
    • Abnormal direction:
      • unstable

Special Tests

  • Patellar tracking: while knee flexes

  • Patellofemoral grind test (chondromalacia, osteoarthritis)
    • Compress patella down while quadriceps tightens
    • Positive when painful

  • Patellofemoral resistance test (chondromalacia, osteoarthritis)
    • Resist patellar motion while quadriceps tightens

  • Patellar apprehension test

Summary of patellar tests:

  • Patellar tracking
  • Patellar grinding
  • Apprehension test

Effusion Tests

  • Large effusion is easy to see

  • Assessment of effusion severity:

    • Look at normal depression medial to patella

    • Minimal effusion: If depression present, “milking” test may demonstrate fluid

    • Mild effusion: If obliterated, fluid can be pushed away but reappears as hand is removed

    • Moderate effusion: If obliterated and fluid cannot be pushed away by hand

    • Moderate/severe effusion: Positive patellar tap (Balloting)

CC VID

Ligament Tests

  • Collateral ligaments: Medial / Lateral
  • Cruciate ligaments: Anterior / Posterior

Collateral Ligament Testing

  • Stress test with knee slightly flexed

  • Alternative technique for collateral ligament testing

Cruciate Ligament Testing

  • Anterior/Posterior Drawer Test

  • Lachman’s test

  • Sagging sign: indicates Posterior cruciate ligament tear

Meniscus Tests

  • McMurray’s test for medial & lateral meniscus

  • Apley grinding test

Gait Assessment

  • Walking gait analysis

Special Tests: Gait Analysis

The Normal Gait Cycle

Stance phase (60%)

  • Heel strike
  • Foot flat - mid-stance
  • Push off

Swing phase (40%)

  • Acceleration
  • Mid-swing
  • Deceleration

Gait Patterns and Interpretation

Gait TypeExplanation
NormalNormal stance and swing phases
AntalgicPainful to weight-bear – short stance phase
LurchShortening – painless limping – normal stance period
CircumductionStiff hip – motion of pelvis compensates
High StepFoot drop – more hip & knee flexion needed to free toes from ground
Tip-toeHeel off the ground

Graph View

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