Knee examination Flashcards
In what general order should you perform the knee examination?
Look: Standing, gait, lying on bed
Feel
Move: Active, passive
Resisted movements
Special tests: Posterior sag sign, anterior draw
How should you appropriately expose the patient to examine their knee?
Ask to wear shorts
Roll up trousers to mid thigh
From what angles should you look at a patient’s knees when they are standing?
Anterior
Lateral
Posterior
Lateral
From the anterior view, give examples of what you look for on the patient’s knees?
Symmetry, or any valgus/varus deformity
Bruising, erythema
Swelling (unilateral or bilateral) eg. inflammation, gout
Quadricep bulk and any wasting
Psoriasis plaques or other skin changes
Position of patella
Swelling of calf: DVT
If there is asymmetry in the quadriceps bulk across the knees, what 2 pathologies can this indicate?
Disuse atrophy
Lower motor neuron lesion
Where should the patella be located relative to the knee joint, and why might it be abnormal?
Patella should be in centre of knee joint
Could be patella dislocation/subluxation which commonly occurs due to falls, collisions, direct force to knee
From the lateral view, what are the 2 main things to look for in the knees, and what can these abnormalities indicate?
Knee hyperextension: Usually due to ACL or PCL injury
Knee fixed flexion deformity: OA, contracture of hamstring muscles, inflammatory arthritis
From the posterior view, what abnormalities should you look for?
Baker’s cyst: Cyst due to swollen and inflamed tissue behind knee, forms a fluid filled sac
Popliteal aneurysm: Usually pulsatile
DVT: one calf is larger than the other, erythema, warmth
What are 4 signs of DVT?
Asymmetrical swelling of the leg or along a vein in the leg.
Pain or tenderness in the leg, which you may feel only when standing or walking
Increased warmth in the area of the leg that’s swollen or painful
Red or discolored skin on the leg.
After you view the patient’s knees when standing, what should you look at next?
Gait
After you look at the patient’s gait, how should you position them, and where should you look at patient from?
Ask patient to lie on bed on their back
Stand at end of bed
When the patient is lying down, what knee abnormalities should you look for?
Symmetry, or any valgus/varus deformity
Bruising, erythema
Swelling (unilateral or bilateral) eg. inflammation, gout
Quadricep bulk and any wasting
Psoriasis plaques or other skin changes
Position of patella
Swelling of calf
What is the first thing you should feel for in a patient’s knees, and why?
Palpate temperature below, surrounding, above knee joint
then compare with other knee
Higher temperature at knee joint can indicate infection, inflammation
After feeling temperature of the extended knee, what should you feel around the patella?
Medial and lateral borders (stabilise the side that isn’t being palpated)
Medial and lateral joint lines
Medial and lateral collateral ligaments
Patellar and quadriceps tendon
What does tenderness of the knee’s medial and lateral joint lines indicate?
Joint capsule tear or irritation
Meniscus tear
Chondromalacia patella: breakdown of cartilage on the underside of the kneecap (patella). When the kneecap rubs against the thigh bone, it hurts and swells
Osteochonritis dissecans: piece of bone and the attached cartilage break down and become loose
Septic, inflammatory arthritis, OA
What does tenderness of the medial or lateral collateral ligaments indicate?
Tendonitis or rupture
After feeling the extended knee, how should you reposition the knee to feel more landmarks?
Flex knee to 90 degrees
What landmarks should you feel on the flexed knee?
Medial and lateral borders (stabilise the side that isn’t being palpated)
Medial and lateral joint lines
Medial and lateral collateral ligaments
Patellar ligament and quadriceps tendon
How do you feel stability of the medial and lateral collateral ligaments of the knee?
With right arm, hold patients leg
With left hand, press on medial aspect of knee to test lateral collateral ligament (varus stress test)
Press on lateral aspect of knee to test medial collateral ligament (valgus stress test)
Knee should not move laterally if ligaments are stable
Why is it important to feel flexed knee?
To feel posterior aspect for popliteal swelling in the popliteal fossa
If you feel a pulsatile mass in the popliteal fossa of the flexed knee, what does this indicate?
Popliteal aneurysm
If its not pulsatile, it could also be a baker’s cyst
When you feel the flexed knee, what 2 bony landmarks should you feel after the patella and popliteal fossa, and why?
Tibial tuberosity: If there is bony elevation and swelling, this can indicate Osgood-Schlatter disease
Fibula head: Tenderness associated with fracture
How do you perform the cross-fluctuational bulge/sweep test in the extended knee?
Cross-fluctuational bulge test if there’s little fluid in the knee
- Bulge of fluid in medial condyle area of knee
- Squeeze fluid out from medial side of patella upwards around over superior patella border, down lateral side
Positive: bulge emerges in medial gutter of knee
How do you perform the patellar tap test in the extended knee?
Patella tap to check if there’s any fluid in the knee joint (knee effusion)
- Put hand above knee and squeeze downwards
- Use thumb/fingers to push down on patella and check if patella bounces
Positive: sensation of patella hitting femoral condyle, which indicates presence of effusion
How do you test active knee flexion?
Ask patient to flex (bend) knees as far as they can by bringing their heel as close to them as possible
(normal range 0-140 degrees)
How do you test active knee extension?
Ask patient to straighten out their legs again so that they are flat
(normal range 180)
How do you test passive knee flexion?
Hold calf with left hand, place right hand on knee joint to feel for crepitus whilst bending knee
How do you test for passive knee hyperextension?
Hold above ankle joint, gently pull upwards
Normal angle 10 degrees
What special test is used to indicate ACL laxity or rupture in the knee?
Anterior draw test:
1. Put fingers on hamstrings to check that they’re relaxed
- Put thumbs onto tibial condyle
- Use elbow to brace lower leg
- Pull gently, observe patient’s face for any pain
Positive: feel large forwards movement of knee, which suggests that anterior cruciate ligament is lax or ruptured
What special sign is used to indicate PCL rupture in the knee?
Posterior sag sign
- Flex knee to 90 degrees
- Observe knee from side, tibia can sag posteriorly in relation to the femur
This indicates rupture of posterior cruciate ligament
What special sign is used to indicate PCL laxity or rupture in the knee?
Posterior draw test
