Knee Examination

Intro

• Wash hands, Introduce self, Check patient name and DOB/CHI, Explain procedure and gain consent

Inspection

• General: patient; mobility aids
• Gait: any antalgic gait, limp, locking knee
• Standing: alignment, varus/valgus deformity, swelling, redness, asymmetry
• Lying: skin (scars, swelling, bruising); joints (effusion, nodules, psoriasis/skin changes); alignment and position
• Measure quadriceps bulk (hand’s breadth above the patella) (NB not always performed)

Feel

• Skin- temperature
• Joint
  • with the knee at 90° flexion, feel the patella, along the joint line
  • note any tenderness, synovial thickening etc
  • also feel for any abscesses/popliteal bursitis
• Effusion
  • Patellar tap
    • Empty the suprapatellar pouch with one hand and push down on the patella with one/two finger(s) of the other hand (positive if the patella sinks before hitting the femur)
  • Cross fluctuation may be performed if there is a large effusion
    • Empty the suprapatellar pouch with the other hand below the patella.  Positive if the pressure/ripple is felt with either hand with alternating compressions
  • For smaller effusions (more common) the bulge test is performed
    • ‘Sweep’ the fluid out of the patella bursa, beginning infero-medially and moving superiorly (superomedial aspect); the repeat laterally beginning superiorly and ending inferiorly.  Positive it there is a ‘bulge’ on the medial side after emptying when the lateral side is swept.

Move

• NB Good to compare with the non-affected knee- test active and passive movements (palpating the joint with passive movement)
  • Flexion (normal 140°) and Extension (normal 0°) (also lift the foot off the bed and look for any hyperextension (normal up to 10°))
• Special tests
  • Collateral ligament stress tests
    • Hold the ankle/lower leg in one arm, and, with the knee at 0 and 30° flexion, apply varus (LCL) and valgus (MCL) stresses
    • Excessive movement suggests tear
  • Cruciate ligaments
    • Drawer test
      • With the knee flexed at 90° and the foot on the bed (often useful to sit on the patient’s foot to support it), with your fingers in the popliteal fossa and thumbs on the tibial tuberosity, apply anterior (ACL) and posterior (PCL) forces on the tibia
    • Lachman’s test
      • with the knee slightly flexed, one hand supporting the thigh, pull the calf anterior (ACL laxity)
  • Menisci
    • McMurray’s test
      • Flex the knee as much as possible, externally rotate the foot, apply a lateral force to the knee and extend the leg (med meniscal stress)
      • Flex the knee, internally rotate and apply a medial force and extend the leg (lat meniscal stress)
    • Apley’s manoeuvre (rarely done in practice)
      • With the patient prone (on front); apply downwards force to knee whilst flexed at 90°, and rotate the foot.
  • Patellofemoral apprehension
    • Flex the knee whilst pushing on the patella laterally

Finish

• Thank patient, wash hands,
• Document/explain findings and suggests further investigations/management

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