(CPA) musculoskeletal knee exam Flashcards by Rasha Rashid

what position and exposure is required for the knee examination?

lying on the couch at a 45 degree angle

knee joint, quadriceps and calf muscles exposed

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what are the components of the knee examination?

position & exposure

look

feel

move (active, passive)

special tests

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how is movement of the knee joint tested?

active testing

passive testing

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which special tests are carried out in the knee examination?

anterior draw for ACL

posterior sag for PCL

medial & lateral collateral ligament

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in the ‘look’ component of the knee exam, what are you looking for?

scars (suggest previous trauma/surgery)

muscle wasting

varus knee deformity (bow-legged)

valgus knee deformity (knock knees)

swelling

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what are knee scars suggestive of?

previous trauma/surgery of the knee joint

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what is knee muscle wasting suggestive of and what must be done if this is observed?

muscle atrophy (maybe due to LMN lesion)

= must do a neurological examination

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what is valgus?

lower leg deformity when the bone at the knee joint is angled OUT and therefore the knees ‘knock’ inwards

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what is varus?

lower leg deformity when the bone at the knee joint is angled IN and therefore the knees face outwards

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what causes knee muscle wasting?

due to disuse (especially if there is chronic pain on movement = arthritis)

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in the ‘feel’ component of the knee exam, what are you feeling/palpating for?

temperature

quadriceps tendon

medial and lateral border of the patella

tibial tuberosity + head of the fibula

popliteal fossa

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how do you feel for the temperature at the knee joint?

patient lying flat with knee joint exposed

use the back of your hands simultaneously and feel for temperature above the patella, at the patella and below

do it at the same time so you can compare the temperatures

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what does a warm knee temperature suggest?

inflammatory condition (e.g. septic arthritis or osteoarthritis)

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what does swelling of the popliteal fossa indicate?

Baker’s cyst (fluid-filled swelling of the tissue of the popliteal fossa)

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what is a knee effusion?

occurs when excess synovial fluid accumulates in or around the knee joint

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why do knee effusions occur?

arthritis

damage to internal structures (e.g. meniscus)

bursitis

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which two feel tests are carried out in a knee examination?

patellar tap method

knee sweep test

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describe how a patella tap test is carried out

ensure the patient’s knee is extended

slide your non-dominant hand down the thigh to empty the suprapatellar pouch

with the non-dominant hand in place above the knee joint, firmly press over the patella with your dominant hand

(moderate effusion = feel a tap as the patella hits the femur)

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describe how a knee sweep test is carried out

ensure the patient’s knee is extended

with your non-dominant hand sweep upward on the medial side of the knee to empty the medial compartment

keeping your non-dominant hand in place, sweep downward on the lateral side of the knee to empty the lateral compartment, with your dominant hand

(small effusion = ripple/bulge of fluid appears on the medial side of the knee from lateral side)

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what does the patella tap test detect?

for detecting large effusions

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what does the knee sweep test detect?

for detecting small effusions

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what is a positive patella tap test?

in moderate effusion = feel a tap as the patella hits the femur

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what is a positive knee sweep test?

if small effusion = ripple/bulge of fluid appears on the medial side of the knee from lateral compartment

in the ‘move’ component of the knee exam, what are you moving?

active flexion & extension of the knee joint

passive flexion & extension of the knee joint

which muscles enable flexion of the knee joint?

hamstring muscles - biceps femoris - semitendinosus - semimembranosus - gracilis

which muscles enable extension of the knee joint?

quadriceps - vastus medius - vastus intermedius - vastus lateralis - rectus femoris

what can damage to the hamstrings and quadriceps cause?

inability to straight leg raise

how is active movement of the knees assessed?

ensure leg is fully extended to begin with ask patient to fully flex and then fully extend the knee in turn

how is active movement of the knees assessed?

ask the patient to relax theri legs you flex and extend the patient's leg to the maximum extent !! test the extensor compartment by lifting the patient's foot with their leg relaxed !!

when assessing movement, which two things do you look for?

pain on movement range of motion

what does pain on movement of the knee suggest?

damage to the structures (e.g. fracture to the meniscus)

what does a reduced range of motion suggest?

could be due to arthritis

when is the range of motion greater: active or passive movement?

usually passive movement

what is the normal angle of motion for the knee joint?

0-140 degrees

how is hyperextension of the knee joint assessed?

ask patient to relax their leg lift the patient's for with the patient's leg relaxed

what is a normal level of hyperextension?

approx 10 degree | anything above 10 degrees is abnormal

what are the two special tests performed during the knee examination?

anterior drawer test for ACL posterior sag test for PCL

what does the anterior cruciate ligament (ACL) prevent?

anterior subluxation (i.e. partial dislocation)

what does the posterior cruciate ligament (PCL) prevent?

posterior subluxation (i.e. partial dislocation)

describe how the anterior drawer test is carried out

flex the patient’s knee to 90 degrees and maintain this position (use your thigh when you sit down to stabilise the foot) check that the hamstring muscles are relaxed and look for posterior sag (posterior subluxation of the tibia on the femur) with hands behind the upper tibia and both thumbs over the tibial tuberosity, pull the tibia anteriorly

what must you check for before carrying out the anterior draw test and why?

must ensure hamstrings are relaxed AND look for posterior sag (!!) as posterior sag causes false-positive anterior drawer sign = should not be interpreted as ACL laxity

what result in an anterior drawer test indicates ACL pathology?

significant movement fowards i.e. >1.5cm upwards indicates an ACL pathology (rupture) often associated with medial ligament injury

movement of how much indicates ACL injury in an anterior drawer test?

>1.5cm upwards = indicates an ACL pathology (rupture) often associated with medial ligament injury

what do the medial and lateral collateral ligaments resist?

valgus and varus stresses

describe how to assess the medial collateral ligaments

flex the knee to 30 degrees place one hand on the medial lower thigh and another hand on the lateral upper calf apply valgus stress (push out) with your hand on the medial upper thigh

describe how to assess the lateral collateral ligaments

flex the knee to 30 degrees place one hand on the lateral lower thigh and another hand on the medial upper calf apply varus stress (push in) with your hand on the medial upper thigh

what does opening of the medial joint line suggest?

opening of the medial joint line suggests damage to the medial collateral ligament

what does opening of the lateral joint line suggest?

opening of the lateral joint line suggests damage to the lateral collateral ligament

what does a positive posterior sag sign suggest?

posterior cruciate ligament tear

what does a positive anterior draw sign suggest?

anterior cruciate ligament tear

what does a positive anterior drawer sign in the present of a positive posterior sag sign indicate?

clinically inconclusive | as positive anterior drawer is a false positive if posterior sag sign present

how do you apply varus stress to the knee joint?

one hand on medial upper calf and another on the lateral lower thigh using thigh hand, push inwards to apply varus stress

how do you apply valgus stress to the knee joint?

one hand on lateral upper calf and another on the medial lower thigh using thigh hand, push outwards to apply valgus stress

when varus stress is applied, which ligament is being tested?

lateral collateral ligament

when valgus stress is applied, which ligament is being tested?

medial collateral ligament