1. Kathy Rainsbury February 2008
Knee Examination
Kathy Rainsbury
February 2008

2. How to diagnose a knee complaint - HISTORY
1) Patient’s age + sex
2) Does the knee swell?
3) Is there a mechanical problem?

3. Age + sex Age Group Males Females 0-12 Discoid lateral meniscus 12-18
Osteochondritis dissecans
Osgood-Schlatter’s
1st patella dislocation
18-30
Longitudinal meniscal tears
Recurrent dislocation patella
Chondromalacia patellae
Fat pad injury
30-50
Rheumatoid arthritis
40-55
Degenerative meniscus lesions
45+
Osteoarthritis

4. Swelling? Effusion Absence of effusion
presence of pathology which must be investigated
XS synovial (inflammatory) fluid/ blood/ pus
Absence of effusion
Does not exclude pathology, but less likely.
Long-standing meniscus lesions/ OA

5. Mechanical problem? Hx of initial injury ‘mechanism’ Knee ‘give way’?
Degree + direction + incapacity
Knee ‘give way’?
Going down stairs/ jumping : cruciate ligament
Twisting/ walking/ uneven ground: meniscus
Knee ‘locks’?
NEVER locks in full extension
Full flexion but limited extension – FB + meniscal (‘click’)
Pain
When? Localise?

6. Investigations
Examine other joints (? Rheumatoid/ psoriasis + other inflammatory arthropathies)
Aspiration + culture of fluid
Bloods
Xray joint (? use)
CXR (if ? TB)
MRI
EUA
Arthroscopy
                                                               

7. Examination
Look
Measure
Feel
Move

8. Surface anatomy
Hollows at side of patella ligament in flexed knee lie over joint line.

9. Surface anatomy 2 - Joint line 10 1 5
Nb suprapatellar bursa communicates with knee joint proper – therefore can milk fluid down in fluid displacement test
- Joint line 5

10. Inspection (ant. + post.)
Symmetry
Swelling/ bruising/ scars/ rash/ deformity/ wasting/ bursae
(Heat)
Patella position – quads/ extensor apparatus intact?
Swelling –
- Localised (bursitis/ meniscal cysts) – image carpenters knee (or parson’s knee to pray)– infrapatellar bursitis
- suprapatellar bursitis ‘housemaid’s knee’
-confined to synovial cavity (effusion, haemarthrosis, pyarthrosis/ SOL)
- generalised (infection/ tumour/ major injury)
Bruising – soft tissues, not normally with meniscal linjuries
Rash – psoriasis
Wasting – pain/ instability/infection/RA
Bursae – in popliteal region, cystic swelling – most commonly semi-membranous bursa
Feel heat with back of hand
Hand under knee – press leg against hand - ? Quads function ok
SLR – to check extensor apparatus with knees hanging over edge of couch

11. Measure Quads circumference
If concerned muscle wasting – 18cm above joint line

12. Palpate Effusion – patellar tap Fluid displacement Tenderness
Bend knee – joint line
Collateral ligaments
Tibial tubercle
Femoral condyles
Evacuate supra-patellar pouch 15cm above knee
Click on patella tap – effusion (NB tense effusion – negative)
Localised tenderness along joint line commonest in meniscus, collateral ligament + fat pad injuries –seen in OA/ Pre-menstrual fluid retention (cured by fat pad excision)
Tibial tuberosity – osgood schlatters (10-16y.os, usually settles with epiphyseal closure) / acute avulsion patella ligament
Femoral condyles – osteochondritis dissecans, esp medial condyle. – teenage males, impingement of fem condyle against tibial spines/ cruciate ligs – AVN.

13. Move Active + passive Extension – 0 deg (? Hyperextension)
Flexion – 135 deg
Extension – springy block – bucket handle meniscus tear
- Rigid block – arthritic (fixed flexion deformity)
Hyperextension – Ehlers danlos syndrome, Charcot’s disease + polio (rare), girls esp. – high patella, chondromalacia patellae, recurrent dislocation, sometime tears ant. Cruciate, medial meniscus or medial ligament. Ballet + high-heels – retard upper tibial epiphyseal growth.

14. Move - instability 1) Valgus stress test (+ve if medial lig torn)
2) Varus stress test ( +ve lat lig torn)
3) Anterior Drawer test (+ve if ant cruciate torn)
Or Lachman test
4) Posterior Drawer test (+ve if post cruciate torn)

15. Instability - rotatory
MacIntosh test / pivot shift test (difficult if patient not under anaesthesia)
MacIntosh – fully extend knee, hold foot in internal rotation, apply valgus stress, gradually flex knee, will jerk at 30 deg as tibial condyle reduces - if rotatory instability. – seen in ACL rupture, anterolateral displacement tibia then on further flexion, shifts back as ITB goes from extensor to flexor.

16. Menisci Feel for clicks, listen for crepitus
McMurrays test – medial + lateral menisci
(or Apley’s grind test)
Medial McMurray’s – leg flexed, foot EXTERNALLY rotated, hip aBducted, - clicks + grating felt while leg smoothly extended
Lateral McMurray’s – lef flexed, foot INTERNALLY rotated, hip abducted – as above.
Meniscal injuries – meniscal tears in young adult, degenerative lesions in middle age
Meniscal cysts – firm on palpation joint line, tender on deep pressure – usually lateral side.

17. And finally…
Gait
Genu varum ‘varus my pig?’
Genu valgus
varus
valgus