Examination Of The Knee

Question 1

1

Answer 1

Wash your hands
Intro

Question 2

2

Answer 2

Inspection with the patient standing, from the front, side and behind. Look for:

o Valgus deformity (knock-knees)
o Varus deformity (bow-legs)
o Genu recurvatum (knee hyperextension)
o Flexion deformity
o Swellings in the popliteal fossa e.g. Baker’s cyst
o Comment on the patient’s stance

(I’d do gait here)

Question 3

3

Answer 3

Position the patient supine on the couch with their hips and knees extended: inspect for:

o Symmetry
o Valgus and varus deformity
o Rashes e.g. psoriasis
o Scars
o Swelling, particularly in the medial fossa (the depression medial to the patella)
o Muscle wasting, particularly in the medial quadriceps (vastus medialis)
o Displacement of the patella
o Fixed-flexion deformity

Question 4

4

Answer 4

Palpitation
Assess the temperature using the dorsum of the hand in the mid-thigh, over the patella and over the upper tibia. Normally the patella region feels cooler than the surrounding tissue. Compare both sides.

Question 5

5

Answer 5

Palpate around the borders of the patella for tenderness

Question 6

6

Answer 6

Palpate behind the knee for popliteal swellings or cysts

Question 7

7

Answer 7

Assess for effusion by performing:

THE BULGE TEST: sweep the hand firmly up the medial fossa and down the lateral fossa. The medial fossa may refill. (Particularly sensitive in picking up a small effusion.

THE PATELLAR TAP

Question 8

8

Answer 8

Flex the knee up to 90 degrees to open the joint line. Palpate the joint line and patellar tendon insertion (tibial tuberosity) for tenderness.

Question 9

9

Answer 9

Assess range of motion

Ask patient to actively flex and extend the knee (normal range of flexion is 135 degrees)

Question 10

10

Answer 10

Assess passive movement by placing one hand on the patient’s knee and flexing as far as possible with the other hand (palpate for crepitus)

Question 11

11

Answer 11

Posterior Sag test: position the patient with the knee flexed to 90 degrees and the foot flat on the bed. Inspect from the side. A posterior sag of the upper tibial with a ‘step’ visible below the patella, is suggestive of PCL damage.

Question 12

12

Answer 12

Anterior draw test

Position the patient with the knee flexed to 90° and the foot flat on the bed. Stabilise the leg using your own forearm – for infection control reasons you should not sit on the patient’s bed. With the fingers of both hands behind the knee and the patients hamstrings relaxed, place your thumbs over the tibial tuberosity and apply a forward pull. Significant movement indicates a positive draw test and suggests anterior cruciate ligament (ACL) damage.

Question 13

13

Answer 13

Lateral collateral ligament test

Flex the knee to 20°. Grasp the patient’s heel with
one hand while exerting pressure against the inside of the knee with the other hand. The varus stress applied will cause lateral gaping in the laterally unstable knee. A small amount of lateral joint gaping is physiological and is the asymmetry of the gaping that constitutes the abnormal finding.

Question 14

14

Answer 14

Medial collateral ligament test

Similar to the previous one but apply a Valgus stress against the lateral aspect of the knee and assess for medial gaping.

Question 15

15

Answer 15

Function

Ask the patient to walk. Observe the toeing angle. (The normal angle is slightly lateral by 10 to 15 degrees)
Is the fair antalgic (painful)? Is there any other abnormality)

(I’d do this earlier on when having a look)

Question 16

16

Answer 16

Completion

Examine the ipsilateral hip and ankle. When examining the ankle, you should use the schema ‘look, feel, move’

Assess the neurological and vascular status of the limb