Knee Examination

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Observation from front

  • Weight distrubtion
  • Deformity (varus/valgus)
  • Swellings (loss of concavities)
  • Scars
  • Redness/rashes
  • Wasting (vastus medialis most prominent)

Patellar Tracking.PNG

Observation from lateral side

  • Hyperextension deformity
  • Fixed flexion deformity
  • Swellings (e.g. meniscal cyst)

Observation from behind

  • Muscle wasting (e.g. calf)
  • Swelling (e.g. semimembranosus bursa, ruptured bakers cyst)

Gait

  • Limp (decreased stance phase – painful, or equal stance phase – non painful e.g. from flexion contracture)
  • Shoulder tilts to the painful side
  • Heel strike, stance, toe off

Screening for internal derangement

  • Squatting
  • Duck walk

Palpation of muscles (knee extended)

Patella

  • Patella (margin, muscle and tendon insertions. Push patella medial side and palpate medially and inferior pole, push laterally and palpate laterally and inferior pole)
  • Patella apprehension test (push laterally and flex 30-40 degrees, rule in and out instability)

OA

  • Crepitus/grind test (push down on patella and flex/ext, look for pain with crepitus rather than crepitus alone)

Fluid

  • Swipe test
  • patella tap

Palpation from side

  • Knee is now flexed
  • Landmarks (lower pole patella is right in joint margin between medial femoral condyle, flat tibial plateau, lateral femoral condyle)
  • Feel for sore meniscus, capsule, osteophytes along line
  • Tibiofibula joint subluxation

Further palpation of landmarks

  • Tibial tubercle
  • Gerdeys tubercle (iliotibial band insertion)
  • Adductor tubercle
  • Medial epicondyle femur, MCL, medial condyl tibia
  • Lateral epicondyle femur, LCL, head of fibula
  • Popliteal artery

Movements

  • Do all as active, passive and resisted
  • Knee flexion
  • Knee extension
  • Quads lag/extensor lag

Ligaments

  • Stress varus/valgus (rule out MCL)

Cruciates

  • Ski jump sign (posterior sag)
  • Anterior drawer (rule in ACL)
  • Pivot shift test (rule in ACL)
  • Lachman test (rule out ACL)
  • Posterior drawer

Meniscus

  • Thessaly test (rule in + out meniscus)
  • Bounce test/snap test (poor)
  • Apley grind test (poor)
  • McMurrays (poor)

Paediatric Examination

A consensus approach to the MSK examination in children was developed by Foster et al in 2011.[1] The underlined components are those that are additional to the adult examination. The italicised components are those that the doctor should be aware of but not necessarily competent in.

With the patient standing:

  • Look for varus/valgus deformity, hyperextension and popliteal swellings
  • Look at the skin for pattern of bruising and rashes
  • Assess gait (see hip)

With the patient lying on couch:

  • Look from the end of the couch for varus/valgus deformity, muscle wasting, scars and swellings
  • Look from the side for fixed flexion deformity
  • Check for passive hyperextension and leg length discrepancy
  • Feel skin temperature
  • With the knee slightly flexed feel/palpate the joint line and the borders of the patella
  • Feel the popliteal fossa
  • Perform a patellar tap and cross fluctuation (bulge sign)
  • Assess full flexion and extension (actively and passively)
  • Option - Assess stability of knee ligaments – medial and lateral collateral – and perform anterior draw test
  • Option – tests for ant knee pain / patellar maltracking / apprehension / patella glide
  • Option – hypermobility, muscle power, entheses,  hamstring tightness, iliotibial band tightness, thigh-foot angle

References

  1. ↑ Foster et al.. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis care & research 2011. 63:1503-10. PMID: 21954040. DOI.