The Knee History and Physical Exam
last authored: Oct 2009, David LaPierre and Susan Tyler
last reviewed:
Introduction
Expose both knees. Also remember that knee pain can be referred pain from the hip.
Inspection
(SEADS)
Examine knee in flexion and extension.
When patient is standing and walking, look for:
- alignment
- Posture, stance,
- gait (antalgic- is there less time spent on wt bearing stance phase?)
- Genu valgus - knock-kneed: knees are together, more than 2.5 cm of space b/w medial malleoli
- Genu varum - bowlegged: when the medial malleoli are pressed together, there is greater than 2.5 cm of space b/w the knees
- Genu recurvatum - knees bend backward
- Baker's cyst - swelling at back of knee
With patient sitting or laying, look for:
- wasting of quads
- swelling
- erythema
- bony deformity
- Look at the suprapatellar region for effusion. Also, a large effusion can wipe out the anteromedial divet.
- flexion contracture
Palpation
(TEST CA)
bony landmarks:
- tibial tuberosity
- patella
- condyles above and below joint line
- fibular head
joint:
- medial and lateral joint lines
- knee is best palpated with knee partly flexed
- temperature: should be cooler than surrounding muscles. A hot knee suggests inflammation. OA knees may have effusions, but should still be cool to touch.
effusion
- bulge sign: test for effusion by 'milking' knee up one side, then down the other
- baloon test: thumb and index finger of one hand on sides of patella, and other hand a few cms above patella
- patellar tap: push down suprapatellar space to compress fluid downwards, then tap patella to feel for a click representing effusion
soft tissue:
- quadriceps tendon (ruptures in 40+)
- patellar tendon (ruptures in youngers)
- quad wasting
- popliteal artery/pulse
- medial and lateral collateral ligaments
- Prepatellar vs. infrapatellar vs. suprapatellar vs. anserine bursa (medial and a frequent and often missed cause of medial pain!)
Range of Motion
ROM (scapulae and glenohumeral joint involvement)
Flexion (130 deg)
Extension (0 deg)
External rotation
Internal rotation
Special Tests
medial and collateral ligaments: hold leg with knee slightly flexed, apply medial and lateral stress
anterior and posterior cruciate (Drawer test): sit on foot, pull tibia forward (ACL), then backward (PCL)
- make sure patient's hamstrings are relaxed, or the test is useless
- posterior drawer: knee will sag
medial and lateral menisci (McMurray's test): palpable clicking or pain suggests meniscal damage
- medial meniscus: put knee in full flexion, externally rotate foot, then slowly extend knee;
- lateral meniscus: put knee in full flexion, medially rotate, then extend knee slowly
Lachman’s test: More specific for ACL tear. Flex knee at 15 deg; stabilize thigh while other hand grasps tibia and pulls anteriorly. Anterior tibial movement of greater than 5 mm = ACL injury
- more specific than anterior drawer
Resources and References
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