Clinical examination notes based on TU/KU curriculum of MBBS in nepal. Hope this will be very much helpful in step wise approach to you people especially during exam time.

1. Knee Examination
Prepared by:
Sunil Baniya
Student, NAIHS-COM,
sanobharyang, ktm, Nepal
1Knee Examination/ Sunil Baniya

2. Complaints:
 Pain
 Swelling
 Stiffness
 Deformity
 Locking
 Giving away
 Limp
 Loss of function
2Knee Examination/ Sunil Baniya

3. Patient is examined in 3 positions:
1. Standing
2. Sitting
3. Lying supine in bed, prone
A. LOOK
1. Gait:
◦ Antalgic gait
◦ Hand to knee gait in quadricep weakness
3Knee Examination/ Sunil Baniya

4. 2. Patient standing:
Front
◦ Knee alignment for deformity
- Varus (bow leg)
- Valgus ( knock knee)
- Windswept deformity
◦ Patellar rotation (to one side)
◦ Foot rotation
◦ Any scars (arthroscopic scars)
◦ Wasting of quadriceps
Figs A to C: Varus/valgus knee/windswept deformity
4Knee Examination/ Sunil Baniya

5. ◦ Swelling around knee (diffuse) = Horse shoe shaped swelling
◦ Localized swelling around knee
- Ganglion
- Meniscal cyst
- Tumors
Side
◦ see only lateral swelling
◦ Ask patient to push knee back & see any
- Flexion deformity
- Recurvatum of knee
5Knee Examination/ Sunil Baniya

6. ◦ By looking from front and side triple deformity of knee
- Flexion
- Posterior subluxation
- External rotation of tibia
Can be made out.
Back
◦ Look in popliteal area for any obvious swelling
- Baker’s cyst
- Gastrocnemius- semimembranosus bursa
- Popliteal artery aneurysm
- Lymphadenopathy
- Soft tissue tumors
6Knee Examination/ Sunil Baniya

7. ◦ Wasting of hamstring and calf muscles
2. Patient sitting:
◦ Knee flexed at 90°, look for position of patella
- High riding patella = patella alta
- Low riding patella = patella baja
3. Patient lying supine on bed:
B. FEEL
a. Temperature: proximal to distal
7Knee Examination/ Sunil Baniya

8. b. Tenderness:
◦ For soft tissue and bony tenderness
◦ Knee flexed at 90°, examined for
- Tenderness along the medial & lateral joint line
◦ Knee extremely flexed
- Tenderness over medial femoral condyle just medial to patellar
lig
(osteoarthritis dessicans of medial femoral epicondyle)
Knee Examination/ Sunil Baniya 8

9.  Knee extended:
- Tibial tuberosity
- femoral condyle
- Tibial condyle
- Suprapatellar pouch
- Retropatellar area (by gliding movement of patella between
thumb and index finger on medial and lateral facets, try to
palpate undersurface of patella)
- Patellar tendon
- Pes anserinus (medial proximal part of tibia)
- Attachement site of collateral ligaments
Fig : Feeling for tenderness (a) This is the best position for eliciting tenderness
around the knee. (b) By pushing the patella to one or other side of the midline
one can feel under its edge
9Knee Examination/ Sunil Baniya

10. c. Synovial thickening:
◦ Knee at extension
◦ Grasp patella in a picer made of thumb and middle finger, pull
toward
- Pulled quite firmly: normal synovial membrane
- Slip off: thickened synovial membrane
d. Distal pulsation:
◦ Dorsalis pedis artery
◦ Posterior tibial artery
10Knee Examination/ Sunil Baniya

11. C. MOVE
◦ First active movement and
◦ then passive movement
◦ Normal Range of Motion:
- Flexion : 0 – 135/140°
- Extension : 0 – 5° (hyperextension)
- Adduction : 0 – 5°
- Abduction : 0 – 5°
- Internal rotation : 5 – 7° or ˂10°
- External rotation : 5 – 7° or ˂10°
11Knee Examination/ Sunil Baniya

12. D. MEASURE
a. For position of patella:
◦ Flex knee at 30°
◦ Measure height of patella (H) & length of patellar tendon (L)
◦ Findings:
- L= H : normal
- L ˃H : patella alta
- L ˂H : patella baja
12Knee Examination/ Sunil Baniya

13. b. Q-angle:
◦ Patient sitting on edge of couch
◦ Leg full extension
◦ 2 lines
- ASIS to centre of patella
- Centre of patella to tibial tuberosity
◦ Measure angle (normally 14° in male & 17° in female)
◦ Increase in angle : valgus deformity (predisposing factor for
chondromalacia)
13Knee Examination/ Sunil Baniya

14. c. Girth of Quadriceps femoris:
◦ Measure 15 – 20 cm above the margin of base of patella
SPECIAL TESTS:
1. For joint effusion
a. Cross fluctuation test
b. Patellar tap
c. Bulge test
d. Juxta patellar hollow test
Fig : Quadriceps wasting is common in all types of joint derangement;
it can be accurately assessed by measuring the thigh girth at a fixed
distance above the joint line of each knee and comparing the two sides.
14Knee Examination/ Sunil Baniya

15. 2. For stability of joint:
a. For cruciate ligaments
i) Anterior cruciate ligamnent (ACL)
 Anterior drawer test
 Lachman’s test
ii) Posterior cruciate ligament (PCL)
 Posterior drawer test
 Sag test
iii) Complex ligament injury
 Pivot shift test
15Knee Examination/ Sunil Baniya

16. b. For collateral ligaments:
i) Varus valgus stress test (in flexion)
ii) Varus valgus stress test (in extension)
iii) Appley’s distraction test
c. For meniscal injury:
i) Mcmurray’s test
ii) Thassaly’s test
iii) Appley’s grinding test
16Knee Examination/ Sunil Baniya

17. Cross fluctuation test:
 Grading of effusion:
- Mild
- Moderate
- Moderate to severe
 Method:
- Applicable only if there is a sizable joint effusion (large joint effusion)
- left hand is used to compress
- and empty the suprapatellar pouch while the right hand straddles the
front of the joint below the patella
- by squeezing with each hand alternately
- Finding: a fluid impulse is transmitted across the joint
17Knee Examination/ Sunil Baniya

18. Patellar tap:
◦ Method:
- The suprapatellar pouch is
compressed with the left hand to
squeeze any fluid from the pouch
into the joint
- With the other hand the patella is
then tapped sharply backwards
onto the femoral condyles
- Finding : In a positive test the
patella can be felt striking the
femur and bouncing off again (a
type of ballottement).
Fig : Testing for intraarticular fluid
– Patellar tap test.
18Knee Examination/ Sunil Baniya

19. The Bulge test:
◦ Method:
- useful method of testing very
little fluid in the joint
-
- squeezing any fluid out of the
suprapatellar pouch
- medial compartment emptied by
pressing on the medial aspect of
the joint
- that hand then lifted away
- and the lateral side is sharply
compressed
- Finding: a distinct ripple is seen
on the flattened medial surface as
fluid is shunted across.
Fig : Doing the bulge test: (a)compress the suprapatellar pouch
(b) empty the medial compartment (c) push fluid back from the
lateral compartment and watch for the bulge on the medial side
19Knee Examination/ Sunil Baniya

20. Juxta patellar hollow test:
◦ Method:
- both knees bent gradually and
observed from below
- a hollow appears lateral to the
patellar ligament
- disappears on further flexion
- Finding: if fluid in the joint,
hollow fills quickly and disappears
at a lesser angle of flexion, or may
not be seen at all
Fig : Testing for intraarticular Fluid: the
juxtapatellar hollow, which disappears in flexion
if there is fluid in the knee.
20Knee Examination/ Sunil Baniya

21. Anterior & Posterior drawer test:
◦ Method:
Finding : Excessive anterior movement (a positive anterior drawer sign)
denotes anterior cruciate laxity; & excessive posterior movement (a
positive posterior drawer sign) signifies posterior cruciate laxity.
21Knee Examination/ Sunil Baniya

22. Lachman test:
◦ Method:
- More sensitive than drawer test
- knee flexed at 20 degrees
- with one hand grasping the lower thigh and
the other the upper part of the leg
- the joint surfaces are shifted backwards
and forwards upon each other
- Finding : If the knee is stable, there should
be no gliding.
Fig : Lachman test
22Knee Examination/ Sunil Baniya

23. Sag test:
◦ Method:
- Bend both knees to 90
degrees
- Look tangentially from
side for posterior sag of
upper tibia
- Importance: indicates
posterior cruciate
ligament rupture.
Fig: Posterior sag in PCL insufficiency
23Knee Examination/ Sunil Baniya

24. Macintosh's Pivot Shift Test:
◦ Method:
- supine with one hand holding the upper
tibia and other hand on the heel
- knee in full extension, internally rotate
and apply valgus force
- Finding: sublux the tibia in
anterolateral instability
- From extension maintaining the
valgus—internal rotation force flex the
knee
- At about 30° flexion, tibia reduces
back with a clunk (action of iliotibial
band)
Fig : Pivot shift test
24Knee Examination/ Sunil Baniya

25. Varus valgus stress test (in flexion):
 side to side stability
 Patient supine
 20° – 30° knee flexion (relaxes posterior
capsule and cruciate ligament) & put
pillow under it
 Apply adduction force (varus) & abduction
force (valgus) alternatively
 Finding : Feel opening of joint line at lateral
side & medial side, and complain of pain
Fig : (a) by gripping the foot close to your
body and guiding the knee alternately
towards valgus and varus (b) by gripping
the femoral condyles (provided your hand
is big enough) and then forcing the leg
alternately into valgus and varus
25Knee Examination/ Sunil Baniya

26. Varus valgus stress test (in extension):
◦ Method:
- In full extension
- Leg in axilla
- Apply varus/valgus force alternatively
- Pain or opening of joint
- Findings:
- collateral ligament injury
- Posterior capsular ligament
- Cruciate ligament tear
Fig : Varus stress test
26Knee Examination/ Sunil Baniya

27. Apley’s grinding test:
◦ Method:
- Prone
- Knee bent at 90
- Compression + medially rotate leg = if pain, lesion
in lateral meniscus
- Compression + laterally rotate leg = if pain, lesion
in medial meniscus
Fig : Apley’s grinding test
27Knee Examination/ Sunil Baniya

28. Apley’s distraction test:
◦ Method:
- Prone
- Knee bent at 90
- Pulled knee
- Medial rotation = for lateral collateral ligament
- Lateral rotation = for medial collateral ligament
Fig : Apley’s distraction test
28Knee Examination/ Sunil Baniya

29. McMurray’s test:
◦ Method:
- Done only when full flexion is
possible
- Flexion + external rotation + varus
force/adduction force
- Gradually extended
- Pain or click felt over medial aspect of
joint line at certain angle
- Finding: tear of medial meniscus (
more part tear, more flexed position
- Similoarly for lateral meniscus,
flexion but internal rotation &
valgus/abduction force
Fig : McMurray’s test
29Knee Examination/ Sunil Baniya

30. Thessaly test:
◦ Method:
- Support
- Ask to satnd on affected leg and flexion at 20
- Ask to twist body 3 times each side alternatively
- Medial joint line pain = medial meniscus tear
- Lateral joint line pain = Lateral meniscus tear
30Knee Examination/ Sunil Baniya

31. THANK YOU
31Knee Examination/ Sunil Baniya