Knee

Question 1

Inspection

Answer 1

Inspect patient standing in underwear
Ventral, dorsal and lateral side.
Spontaneous posture then ask to stand upright with feet to each other
Look at bony structure and muscles with contour (atrophy ?)
Ventral side
Q-angle: quadriceps angle. 18deg women 13 deg men. Femur to iliac spine between hip-tibia.
Genu Varum: knees more angled outside
Genu Valgum: knees more angled inside
On dorsal side: swelling, discoloration poplietal fossa ?
Lateral side: genu recurvatum (knees curved back: hyperextension)
Ask patient to walk: stride length, load on right/left leg, symmetry, flexion and contraction knee, symmetry torso rotation

Question 2

Active movement examination

Answer 2

Lie completly flat on table
Flexion with heel against buttocks
extension : press poplietal fossa against table
Inspect movement and asses:
course of movement, occurrence of pain, occurrence of crepitations, lateral displacement of patella (in that case palpation)

Question 3

Passive movement examination

Answer 3

1 hand palpate both side of joint space
other hand hold the ankle or calcaneus
Do flexion and extension
Then exo and endoration: knee flexed at 90° and turn foot. Exo: feet to outisde. Endo: feet to inside
Inspect movement and asses:
course of movement, occurrence of pain, occurrence of crepitations, lateral displacement of patella (in that case palpation)

Question 4

Muscle test

Answer 4

Isometric

Patient sit with legs hanging down
Flexor:
Pull leg of patient towards you and patient pulls towards him
Extensor:
Push towards patient and patient push out.

Ask if any pain

Question 5

Palpation

Answer 5

Ask patient to indicate if and where they feel pain. Note muscle tone and swellings.
Supine:
Palpate the skin, Hoffa’s fat pad (under patella, knee extended on either side of patella ligament), the majority of muscles and the patella (can be moved side ways and up/down) with the knee in 0° flexion. The other structures should preferably be palpated at 90° flexion of the knee
collateral ligements (on either side of knee, can have need a bit flexed)
Sitting:
Femur condyle(top of bone “ball”) and epicondyle (side of bone “ball”)
tibial condyle and plateau
caput fibula
medial and lateral joint line

Question 6

Specific tests

Answer 6

Test for suspected fluid accumulation
Clarke’s sign (patellar grind test)
Stability tests
McMurray test (meniscus test)

Question 7

suspected fluid accumulation

Answer 7

Considerable fluid suspected:
Hand stroke over thigh then stay in position over knee
Other hand press on patulla and look if any balletments
Minor fluid accumulation (bulge test, sweep test, katz symptom):
Hand stroke from under knee to interior cranial
other hand stroke from above knee to exterior caudal.
If fluid will see the fluid fill

Question 8

Examination

Answer 8

Inspection ( + q angle and gait pattern )

Active movement ( flexion and extension)

Passive ( flexion, extension, endo, exo )

Muscle test

Palpation

Specific tests: fluid, patellar grind, stability & mcmurray

Question 9

Clarke’s sign, signe de rabot

Answer 9

patellar grind test
patient is supine
slide hand on thigh down knee and press down
ask patient to contract quadriceps (thigh muscle)
Compare left and right

positive: if pain only on the side of the complaint. Often false positive.

Question 10

McMurray Test

Answer 10

Meniscus test

patient supine with both legs extended.
Put leg in 90° flexion
1 hand hold foot at calcaneus, other feels joint space on the knee.
Bring leg to maximum flexion
Exorotate foot (medial meniscus) and then extend leg
Do same but endorotate foot (lateral meniscus)

Positive: painful snap

Question 11

Lachman test

Answer 11

Stability of cruciate ligament
indicated with fluid accumulation, trauma

patient supine, knee flexed at 15°, push on thigh and pull on on tibia
Note: abnormal mobility, pain, muscular defense, left right difference

Question 12

Drawer test

Answer 12

Stability cruciate ligament

patient supine, knee flexed at 90°
do with foot straight, endo and exo rotated
pull proximal tibia
Do both legs

note: abnormal mobility, muscular defense, pain, left right difference

Do same but by pushing the proximal tibia

gravity drawer test/ posterio sag
patient supine
hips and knee at 90°, compare knee height

Question 13

Collateral ligaments

Answer 13

Stability test
patient supine
pull leg outside examination table at a 30° angle. Pull on thigh and push on tibia (lateral collateral). Then the opposite, push on thigh and pull on tibia (medial collateral).
Do the same with 0° angle.