This document provides an overview of how to examine the knee joint, including: 1. Taking a history by gathering demographic data, chief complaints, pain details, swelling details, injury mechanism, medical history, and sports history. 2. Examining the patient in standing, sitting, and supine positions to look for deformities, swelling, range of motion, tenderness, and special tests for effusion, stability, and meniscal/ligament injuries. 3. Performing measurements of the patella position, Q-angle, and quadriceps girth. 4. Testing for injuries to the ACL, PCL, collateral ligaments, and menisci through various stress tests.

1. History and Examination of Knee Joint
Moderator: Dr Sushil Poudel
Presenter: Dr Ajay Shah
Department of orthopedics and trauma

2. History
Demographic data
• Age
• Gender
• Address
• Occupation

3. Chief complaint
In patient’s own word
Pain
Swelling: immediate , delayed
Stiffness
Giving way
Locking
Limping
Deformity
Functional difficulty

4. Pain
• Location of pain
Anterior
Posterior
Medial
Lateral
• Onset of pain
• progression
• Character of pain
• Aggravating and relieving factors

5. Swelling
• History of swelling?
• Was the swelling immediate or delayed?
Synovial swelling –takes 8-24 hours to develop
Haemarthrosis- immediate swelling
• Site of swelling?
• Area of swelling?
Localized swelling- extracapsular injury
Generalized swelling- intracapsular injury

6. • Any clicking or pop sound during injury?
Indicates ligament tear (mainly ACL) in knee joint
• Any “ give way or catch” ?
Give way- instability
Catch(lock)- meniscal injury , loose bodies

7. Mechanism of injury
Helps to predict the injured structure
• Contact or non contact injury?
If contact , what part of the knee was contacted?
Anterior blow- Bony avulsion
Valgus force- MCL injury
Varus force- LCL injury
• Non contact injury with pop sound , most likely ACL
tear
• Was foot of affected knee planted on the ground

8. ACL injury
• Common in weight bearing , slight flexion and rotation in either directions
• Anterior translator force on proximal tibia
• Hyperextension injury
PCL injury
• Posterior translation of tibia
• Dashboard trauma
• Hyperextension
Meniscal injury
• Twisting force in weight bearing with slightly flexed knee
• Medial meniscus more commonly injured than lateral

9. Medical History
• History of knee injury or surgery
• Previous attempts to treat knee pain including use of medications, supporting devices and
physical therapy
• History of gout, pseudogout, rheumatoid arthritis or other degenerative joint disease.
• Past history of TB and other chronic illness

10. Family History
• Inflammatory arthritis
• Spondyloarthritis
• Connective tissue disorders
• Hemophilia

11. Sports Specific History
• Total duration of play
• Total practice/training session
• Exercise protocol- warm up/cool down
• Competition

12. Examination
Patient is examined in 3 positions
1 Standing
2 Sitting
3 Lying supine in bed , prone

13. Standing Position : Look
Front
• Gait
• Deformity
Varus
Valgus
Windswept deformity
• Patellar rotation
• Any scars ( arthroscopic scars)
• Wasting of quadriceps
• Swelling around knee
Diffuse
Localized: ganglion, meniscal cyst, tumors ,prepatellar bursitis, infrapatellar bursitis

14. Deformities

16. Swelling

17. Look
Side
• See any lateral swelling
• Ask patient to push knee back and see any
Flexion deformity
Recurvatum of knee
• By looking from front and side triple
deformity of knee can be made out
Flexion
Posterior subluxation
External rotation of tibia

18. Look
Back
• Look in popliteal area for any obvious
swelling
Baker’s cyst
Popliteal artery aneurysm
lymphadenopathy
Soft tissue tumors
• Wasting of hamstring and calf
muscles

19. Supine position
Feel
1 Skin temperature : compare
2 Tenderness
• For soft tissue and bony tenderness
• Knee flexed at 90 degree , examined for
Tenderness along the medial and lateral joint
line
• Knee extremely flexed
Tenderness over medial femoral condyle just
medial to patellar ligaments ( osteoarthritis
dessicans of medial femoral epicondyle)

20. Feel
Structures
1 Quadriceps tendon
2 Edge of patella
3 Medial collateral ligament
4 Joint line
5 Lateral collateral ligament
6 Patellar ligament

21. Feel
3 Synovial thickening
• Knee in extension
• Grasp the edge of patella in a pincer made of thumb
and middle finger, lift the patella forwards
 Grasped quite firmly: normal synovial membrane
 Slip off: thickened synovial membrane
4 Pulsation
• Popliteal artery
• Distal pulsation
Dorsalis pedis artery
Posterior tibial artery

22. Move
First active movement and
Then passive movement
Normal range of motion
• Flexion: 0-150 degree
• Extension: 0-5
• Adduction: 0-5
• Abduction: 0-5
• Internal rotation: 5-7
• External rotation: 5-7

24. Sitting position
Measure
1 For position of patella
• Flex knee at 30 degree
• Measure distance between lower pole of
patella and upper tibial limits (A) and distance
of patellar articular surface (B)
• Findings
B=A: Normal ( 0.6-1.3)
B>A: Patella alta
B<A: Patella baja

25. Measure
2 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 degree in male and
17 degree in female)

26. Measure
3 Girth of Quadriceps femoris
• Measure 15-20 cm above the margin of
base of patella
• Measure at the same level in both limbs
and compare the two sides

27. Special Tests
For joint effusion
a. Cross fluctuation test
b. Patellar tap
c. Bulge test
d. Juxta patellar hollow test

28. Cross Fluctuation Test
• Applicable only if there is a sizable joint effusion (
large joint effusion)
• One hand is used to compress and empty the
supra patellar pouch
• While other hand straddles the front joint below
the patella by squeezing with each hand
alternatively
• Findings: a fluid impulse is transmitted across the
joint

29. Patellar Tap
• For moderate effusion
• A hand is placed over the supra patellar pouch and
pressed on to occlude this space.
• The patella is then pressed with the other hand to
allow the patella to touch the femoral trochlea.
• In the presence of moderate effusion this gives the
sensation of a tap.

30. Bulge Test
• Performed for a small effusion.
• Here the supra patellar pouch is occluded
with one hand.
• Stroke the lateral gutter and watch the
fluid move across to the medial side with
a bulge (or vice versa).

31. Juxtapatellar Hollow Test
• Normally , when knee is flexed, a hollow
appears to the patellar ligament and
disappears with further flexion
• If there is excess fluid, the hollow fills and
disappears at a lesser angle of flexion

32. For Stability of Joint
A. For cruciate ligaments
1. Anterior Cruciate Ligament
• Anterior drawer test
• Lachman’s test
• Pivot shift test
2. Posterior cruciate ligament
• Posterior drawer test
• Sag test

33. 2. For collateral ligaments
• Varus stress test
• Valgus stress test
• Appley’s distraction test
3. For meniscal injury
• McMurray’s test
• Thassaly’s test
• Appley’s grinding test

34. Anterior Drawer Test
• Knee flexed to 90° and the feet fixed to the couch
by sitting on the patient’s feet.
• Both hands are used to grasp the upper tibia, with
the thumbs on the tibial tubercles.
• At this angle of flexion the anterior tibial condyles
should be anterior to the corresponding femoral
condyles.
• From the neutral position excessive forward
movement indicates a positive anterior drawer sign

35. Anterior Drawer Test

36. Lachman Test
• More sensitive than drawer test
• Useful if knee is swollen and painful
• Knee flexed at 20 degree
• With one hand grasp the lower thigh and with other
the upper part of leg
• The joint surfaces are shifted backwards and
forwards upon eachother
• If the knee is stable there will be no gliding

37. • In some patients with large thighs or
examiners with small hands, it is better to fix
the femur over the examiner ’s flexed knee
while displacing the tibia with the other hand.

38. Posterior Drawer Test
• From the neutral position excessive backward
movement indicates a positive posterior
drawer sign

39. Sag Test
• Bend both knees at 90 degrees
• Observe tangentially at the level of tibial tubercles from side
• A positive sag indicates ruptured PCL
• If there is a positive posterior sag then quadriceps active test can be performed

41. Quadriceps Active Test
• It is performed by fixing the foot and asking the
patient to try to extend the leg.
• This test works by contractions of the quadriceps
being transmitted to the tibial tubercle via the
patella and the patellar tendon.
• If there is a posterior sag the quadriceps will pull
the tibia forwards of about 2mm or more.

42. Pivot Shift Test
• Supine position
• One hand holding the upper tibia and other
hand on the heel
• Knee in full extension, internally rotate and
apply valgus force
• Begin to flex knee while maintaining the
inward rotation force
• At approx. past 30 degree, a positive result
will produce clunk as the iliotibial band takes
over flexion and reduces tibia

43. Losee Pivot Shift Test
• Test for anterior subluxation of lateral tibial condyle
• Knee partly flexed
• Valgus force
• Same time pushing fibular head anteriorly
• Start extension of knee, if full extension is reached ,
clunk will occur, as the lateral tibial condyle
subluxes forward ( if rotatory instability is present)

44. Jerk Test
• Test for anterior subluxation of lateral tibial
condyle
• Grasp foot between arm and chest
• Apply valgus force
• Lean over to rotate foot internally and flex the
knee
• If test is positive, lateral femoral condyle will
appear to jerk anteriorly because the tibia is
firmly held

45. Varus Stress Test
• Lie supine
• Knee flexed at 20-30 degree
• One hand at medial aspect of knee and other at
lateral aspect of ankle
• Varus force away from mid line
• Finding : Feel opening of joint line at lateral side
and complain of pain

46. Valgus Stress Test
• Lie supine
• Leg abducted
• Knee flexed at 20-30 degree
• One hand at lateral aspect of knee and
other at medial aspect of ankle
• Valgus force away from mid line
• Finding : Feel opening of joint line at
medial side and complain of pain

47. Apley’s Distraction Test
• Prone
• Knee flexed at 90 degree
• Pulled knee
• Medial rotation= lateral collateral ligament
• Lateral rotation= medial collateral ligament

48. McMurray Test
• Supine with the knee flexed.
• One hand on the top of the knee with the fingers
and thumbs positioned to palpate the joint line,
and the other hand under the heel
• Then compress the joint by pushing down on the
top hand while the lower hand controls flexion and
can also rotate the leg, thereby stressing each
compartment in varying degrees of flexion.
• Most specific for a tear of the posterior horn of the
medial meniscus

49. Thessaly Test
• Support
• Ask to stand on affected leg and flexion at 20
degree
• Medial joint line pain= medial meniscus tear
• Lateral joint line pain= Lateral meniscus tear

50. Apley’s Grinding Test
• Prone
• Knee flexed at 90 degree
• Compression + medially rotate leg= if pain, lesion
in lateral meniscus
• Compression + laterally rotate leg= if pain, lesion
in medial meniscus

51. Test for posterolateral instability
External rotation recurvatum test
• Supine position
• Stand at the end of examination couch
• Lifts the legs by great toes
• Positive test: knee falls into external rotation, varus and
hyperextension

52. Posterolateral Drawer Test
• Knee flexed to 90 degree
• Foot in external rotation
• Backward pressure on tibia
• Excessive travel on lateral side is indicative of
posterolateral instability
• Usually associated with injuries to PCL and lateral
ligament complex

53. Jakob’s Reversed Pivot Test
• Knee flexed at 90 degree
• External rotation of foot
• Apply valgus force
• Extend the knee
• Positive test: posteriorly subluxed lateral tibial
plateau suddenly reduces at about 20 degree

54. Dial Test
• Prone position
• External rotation of knee measured at 30 degree and 90
degree of flexion
• External rotation is measured by noting the foot- thigh angle
• In the rare case of isolated PLC injury, > 10 degree increase in
external rotation is noted at 30° but this is less so at 90°.
• When combined PCL and PLC injuries are present, > 10 degree
increase in external rotation is noted in both positions

55. Patellofemoral pathology
Apprehension test
• Try to displace patella laterally while flexing the knee
from fully extended position
• If there is tendency to recurrent dislocation, the
patient resists further flexion for fear of patella
dislocating

56. Clarke’s Test
• Use to demonstrate patellofemoral pathology
such as chondromalacia and patellofemoral
arthritis.
• Keep hand over the suprapatellar pouch with
gentle pressure on the superior pole of the
patella
• Ask the patient to contract the quadriceps or to
attempt a straight leg raise.
• Pain in the patellofemoral joint indicates that
pathology is present

57. References
• Examination techniques in orthopedics 2nd Edition
• Clinical orthopedic examination 6th Edition
• Apley and Solomon’s system of orthopedics and trauma 10th Edition

58. THANK YOU