Knee examination

Question 1

What is the first part of any introduction to an examination?

Answer 1

Wash hands
Intro self
Pt details

Question 2

Explain a knee exam to a patient

Answer 2

I’ve been asked to examine your knee joints today, it’s going to involve me having a general inspection, feeling and moving your joints and then perform a few special tests

Question 3

What else would you include in your intro?

Answer 3

Expose ok?
Chaperone?
Pain or discomfort?

Question 4

When inspecting the bedside what do you look for?

Answer 4

Look for mobility aids/adaptations -> Walking stick / wheelchair.

Question 5

When inspecting from the front what do you look for?

Answer 5

Scars -> Previous surgery/trauma.

Swelling -> Effusions/inflammatory arthropathy/septic arthritis.

Asymmetry/leg length discrepancy.

Valgus (knock-knee) or varus (bowed leg) deformity.

Quadriceps wasting -> Reduced mobility secondary to injury/arthritis/nerve injury.

Question 6

When inspecting from the side what do you look for?

Answer 6

Knee hyperextension.
Flexion deformity.

Question 7

When inspecting from the back what do you look for?

Answer 7

Scars.
Asymmetry.
Popliteal swellings -> Baker’s cyst / Popliteal aneurysm.

Question 8

What do you assess when observing gait?

Answer 8

Is the patient demonstrating a normal heel strike/toe off gait?
Is each step of normal height?
Is the gait smooth + symmetrical?
Any obvious abnormalities – Antalgic/waddling/broad-based.

Question 9

In a knee exam what do you feel for?

Answer 9

Assess the temperature using dorsum of hand in the mid

Palpate the knee and surrounding structures when extended

Palpate the knee and surrounding structures when flexed 90°

Question 10

What do you palpate / assess when feeling the knee and surrounding structures when extended?

What does tenderness / a positive test indicate?

Answer 10

Quadriceps tendon;
Tenderness may suggest tendonitis.

Palpate the medial + lateral patella facets for tenderness whilst stabilising one side of the patella + palpate with fingertip of other
Tenderness may represent injury/patellofemoral
arthritis.

Patellar tap;
Empty the suprapatellar pouch by sliding left hand
down thigh.
Keep the left hand in position + use right hand to
press downwards on the patella with fingertips.
If there is fluid present there will be a tap as the
patella bumps against the femur.

Question 11

What do you palpate / assess in the knee and surrounding structures when flexed 90°

What does tenderness indicate?

Answer 11

Patella tendon
Tenderness may suggest tendonitis.

Tibial tuberosity.

Joint line;
Tenderness may suggest meniscal tear.

Head of fibula.

Medial + lateral collateral ligaments.

Popliteal fossa –
Baker’s cyst / Popliteal aneurysm.

Question 12

What type of movement do you want to assess in a knee exam?

Answer 12

Active and passive

Question 13

What active movement do you want to test in a knee exam?

What instructions would you give to a patient?

What is the normal ROM?

Answer 13

Knee flexion;
“Can you move your heel as close to your bottom as you can?”
Normal ROM 135°

Knee extension;
“Now straighten your leg out as best as you can”.
Normal ROM 0°

Question 14

What passive movement do you want to test in a knee exam?

How do you perform these?

What is the normal ROM?

Answer 14

Knee flexion and extension whilst feeling the patella for crepitus.

Hyperextension;

Elevate both legs by the heels, <10° is normal.

Question 15

What special tests are included in a knee exam?

Answer 15

Anterior draw test

Posterior sag test

Lateral collateral ligament test

Medial collateral ligament test

Question 16

How do you perform the anterior draw test?

What does significant movement indicate?

Answer 16

Position the patient with knee flexed to 90° and foot flat on bed.
Stabilise the leg with the forearm across.
Position fingers behind the knee, thumb on tibial tuberosity, relax as much as possible + apply forward pull.

Positive draw test -> suggests anterior cruciate ligament damage.

Question 17

How do you perform the posterior sag test?

What does posterior sag indicate?

Answer 17

Position the patient with knee flexed to 90° and foot flat on bed.
Inspect from the side.
Posterior sag of upper tibia with a ‘step’ visible below the patellar.

Suggests posterior cruciate ligament damage.

Question 18

How do you perform the lateral collateral ligament test?

How would you identify LCL damage?

Answer 18

Flex the knee to 20°
Grasp the patient’s heel with one hand and exert pressure against the medial knee with the other.

If the LCL is damaged your hand should detect the lateral aspect of the joint opening up.

Question 19

How do you perform the medial collateral ligament test?

How would you identify MCL damage?

Answer 19

Flex the knee to 20°
Grasp the patient’s heel with one hand and exert pressure against the lateral knee with the other.

If the MCL is damaged your hand should detect the medial aspect of the joint opening up.

Question 20

Upon completing the exam what do you do first?

Answer 20

Thank patient
Wash hands

Question 21

To complete my exam….

Answer 21

I’d like to examine the patients ipsilateral hip and ankle and perform a full neurological and vascular examination of the patient’s lower limb