physical examination of knee

1. Knee Examination
Broto Suwadji, MD

2. ANATOMY
•Osseous Structures
•Extraarticular Structures
•Intraarticular Structures

3. Anatomy
Osseous Structures
• Distal femur
• Proksimal Tibia
• Patella

4. • femoral condyles are
two rounded
prominences
• Anteriorly flattened
• medial condyle is
longer
• lateral condyle is wider

5. • two rather flat surfaces
• separated in the midline
by the intercondylar
eminence
• medial and lateral
intercondylar tubercles
• Anterior and posterior
to the intercondylar
eminence

6. • triangular sesamoid
bone
• wider at the proximal
pole
• patella is divided by a
vertical ridge larger
lateral articular facet
• increase the power of
extension

7. Extraarticular Tendinous
Structures
• Synovium
• Capsule
• collateral ligaments
–medial n Lateral
• Musculotendinous
–gastrocnemius, the medial and
lateral hamstring groups, the
popliteus, and the iliotibial band)

8. Intraarticular Structures
• medial and lateral
menisci
• the anterior and
posterior cruciate
ligaments

9. • Function
– increase the contact
area
– Weight transmission
• Prone to injury,
particularly during
unguarded movements
• medial meniscus is
especially vulnerable

10. • medial meniscus is especially vulnerable
because
–firmly attached at three widely separated
points: the anterior horn, the posterior horn
and to the medial collateral ligament
–deep portion of the medial collateral
ligament blends with the posteromedial
capsule

11. Knee
Examination

12. SYMPTOMS
• Pain
• Swelling
• Stiffness’
• Locking
• Deformity
• Giving way
• Limp

13. SIGNS
Look – Feel – Move
• SIGNS WITH THE PATIENT UPRIGHT
• SIGNS WITH THE PATIENT SITTING
• SIGNS WITH THE PATIENT LYING SUPINE
• SIGNS WITH THE PATIENT LYING PRONE

14. SIGNS WITH THE PATIENT
UPRIGHT
• Deformity
– (valgus or varus or hyperextension
(Normally the knees and ankles can touch in the midline)
• Quadriceps,patella and patellar ligament
• Gait
– stance phase
• fixed flexion deformity or a hyperextension deformity
• lateral or medial thrust
– swing phase
• knee moves freely or is held in one position

18. SIGNS WITH THE PATIENT
SITTING
• knees dangling at 90 degrees of flexion
– patella alta
– patella baja
• ask the patient to straighten each knee in turn , observe how the
patella moves upwards
• Q-angle14 degrees in men and 17 degrees in women

23. SIGNS WITH THE PATIENT LYING
SUPINELook
• position of the knee
– valgus or varus,
– incompletely extended,
– hyperextended
– lumps or bumps
• Wasting
• Bruising
• scars or sinuses
• shape and position of the patella

25. Feel
• skin temperature
• soft tissues and bony outlines
• Synovial thickening

26. soft tissues and bony outlines

28. 1, quadriceps tendon; 2, edge of patella; 3,
medial collateral ligament; 4, joint line; 5,
lateral collateral ligament; 6, patellar ligament

29. Synovial thickening

30. SIGNS WITH THE PATIENT LYING
SUPINE
Move
• Passive extension
• Active extension
• Passive and active flexion
– The ‘heel-to-buttock’ distance
• Internal and external rotation
• Crepitus
• Movement with compartmental loading

31. • A : Normal Range :
– 0-135⁰
• B : Hiper extension
– 5⁰ hyperext - 140⁰
• C : Fixed flexion
deformity
– 10⁰ – 60⁰

32. The ‘heel-to-buttock’ distance

33. Tests
• Tests for intra-articular fluid
• The patello-femoral joint
• Tests for stability
• Tests for meniscal injuries

34. Tests for intra-articular fluid
• Juxtapatellar hollow
• Patellar tap test
• Bulge test
• Cross fluctuation

35. Juxtapatellar hollow

36. Patellar tap test

37. Bulge test

38. Cross Fluctuation

39. The patello-femoral joint
• size, shape and position of the patella are noted
• the ‘friction test’
– Moving the patella up and down while pressing it lightly against
the femur
• Apprehension test
– Pressing the patella laterally with the thumb while flexing the
knee slowly may induce anxiety and sharp resistance

40. Apprehension test

41. Tests for stability
• Collateral ligaments
– Varus – Valgus stree test
– The test is performed at full extension and again at 30 degrees of
flexion
• Cruciate ligaments
– both knees flexed 90 degrees
– feet resting on the couch
– upper tibia is inspected from the side
 ‘sag sign
 drawer test
 Lachman test

42. Varus Valgus stress test

43. Sag Sign

44. Drawer Test

45. Lachman Test
• knee is flexed 20 deg
• one hand grasping the lower thigh
• Other upper part of the leg
• Shifted backwards and forwards

46. Tests for meniscal injuries
• McMurray’s test
– knee is flexed as far as possible
– hand steadies the joint
– other rotates the leg medially and laterally
– knee is slowly extended
– repeated several times
– knee stressed in valgus or varus
– feeling and listening for the click
A positive test is helpful but not pathognomonic; a negative test does not
exclude a tear

48. • Thessaly test
• based on a dynamic reproduction of load transmission
• affected knee flexed to 20 degrees
• foot placed flat on the ground
• instructed to twist his or her body to one side

50. SIGNS WITH THE PATIENT LYING
PRONE
• Scars or lumps in the popliteal fossa
• Swelling: midline (capsule), one side (bursa), Baker’s cyst
• Apley’s test
• Lachman’s test

51. Apley’s test
• patient prone
• knee is flexed to 90
degrees
• rotated while a
compression force
applied
• grinding test 
meniscus is torn
• distraction test 
ligament damage