This document provides guidance on performing a thorough knee examination. It outlines steps to look, feel, move, and perform special tests on the knee to identify various injuries and conditions. The look section describes examining alignment, swelling, and other visual indicators. The feel section details palpating areas like the joint line, patella, and ligaments. Special tests are described to check the meniscus, collateral ligaments, cruciate ligaments, and other structures. It emphasizes comparing both knees and considering referrals from other joints.
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.
Palpation of knee joint can be done in various positions based on the comfort of the patient and therapist. If the patient is sitting, high sitting is a good position to start. If not, supine is an alternative position where the patient is most relaxed; as shown by Hutchinson in the BJSM video.
Practice is the key to master the examination. The students should be aware of the location of the structures in such a way that you should be able to see through the skin and locate the structures underneath. Practice by marking the skin for various structures under the skin.
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.
Palpation of knee joint can be done in various positions based on the comfort of the patient and therapist. If the patient is sitting, high sitting is a good position to start. If not, supine is an alternative position where the patient is most relaxed; as shown by Hutchinson in the BJSM video.
Practice is the key to master the examination. The students should be aware of the location of the structures in such a way that you should be able to see through the skin and locate the structures underneath. Practice by marking the skin for various structures under the skin.
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...drashraf369
a comprehensive and examination oriented presentation of clinical examination of knee joint.contains lot of demonstrations and tips.author is dr mohamed ashraf,professor and head of orthopaedics,govt TD medical college hospital,alleppey,kerala,india. drashraf369@gmail.com
Medial patellofemoral ligament.
stabilizer of patella during initial 30 degree of flexion.
More than 18 techniques of reconstruction described.
Runs in layer 2 on medial aspect of the knee.
Origin- 1.9mm anterior/3.8 mm distal to adductor tubercle.(Laparade JBJS- Am.07)
Insertion – proximal 2/3 of patella
Along Distal edge of VMO
Broad insertion over 28.2+_ 5.6 mm over proximal 2/3 patella.
Average length 59.8mm +_ 4.8mm.
Passive- Trochlear constraints
Depth ,length(Height)
Patellar engagement
Capsular ligamentous tethers, especially MPFL
(Hautamaa, Fithian et al. 1998)
Dynamic elements
Simulated muscle tension has little effect on patellar mobility. Regardless of flexion angle
(Scnavongers, Farahmand et al 2003
Medial patellofemoral ligament reconstruction ---- an update on techniques used. This lecture was taken by me at Trinity Arthroscopy Course, Chandigarh.
Mpfl tech - MPFL Reconstruction for Patellar InstabilityDelhiArthroscopy
MPFL Rec onstruction for Patellar Instability - By Dr Shekhar Srivastav .
Surgical Technique
- Diagnostic Arthroscopy
- Look for any Osteochondral fragment
(Loose body)
- Look for any Chondral damage
- Patellar tracking though Supero-lateral portal
Post-op Protocol
Ambulation with stick and Knee Brace- 3 wks
ROM exer – Next day upto 300 and progress
Review every 2 wks,6 wks,3 mnths,6 mnths and
yearly thereafter
Post-op assessment (Crosby-Insall criteria)
Excellent- No pain,normal activity
Good- Occasional pain,discomfort
Fair/Poor- Pain,loss of flexion,recurrent
dislocation/subluxation
Worse- Pain increased,displacement more
frequent
Caution
Must avoid overtightening-
Medial instability
Medial patellar arthritis
Patellar fractures
Preexisting Chondromalacia
Details @ http://www.delhiarthroscopy.com/
Knee clinical examination for orthopaedic residents.dr mohamed ashraf TD medi...drashraf369
a comprehensive and examination oriented presentation of clinical examination of knee joint.contains lot of demonstrations and tips.author is dr mohamed ashraf,professor and head of orthopaedics,govt TD medical college hospital,alleppey,kerala,india. drashraf369@gmail.com
Medial patellofemoral ligament.
stabilizer of patella during initial 30 degree of flexion.
More than 18 techniques of reconstruction described.
Runs in layer 2 on medial aspect of the knee.
Origin- 1.9mm anterior/3.8 mm distal to adductor tubercle.(Laparade JBJS- Am.07)
Insertion – proximal 2/3 of patella
Along Distal edge of VMO
Broad insertion over 28.2+_ 5.6 mm over proximal 2/3 patella.
Average length 59.8mm +_ 4.8mm.
Passive- Trochlear constraints
Depth ,length(Height)
Patellar engagement
Capsular ligamentous tethers, especially MPFL
(Hautamaa, Fithian et al. 1998)
Dynamic elements
Simulated muscle tension has little effect on patellar mobility. Regardless of flexion angle
(Scnavongers, Farahmand et al 2003
Medial patellofemoral ligament reconstruction ---- an update on techniques used. This lecture was taken by me at Trinity Arthroscopy Course, Chandigarh.
Mpfl tech - MPFL Reconstruction for Patellar InstabilityDelhiArthroscopy
MPFL Rec onstruction for Patellar Instability - By Dr Shekhar Srivastav .
Surgical Technique
- Diagnostic Arthroscopy
- Look for any Osteochondral fragment
(Loose body)
- Look for any Chondral damage
- Patellar tracking though Supero-lateral portal
Post-op Protocol
Ambulation with stick and Knee Brace- 3 wks
ROM exer – Next day upto 300 and progress
Review every 2 wks,6 wks,3 mnths,6 mnths and
yearly thereafter
Post-op assessment (Crosby-Insall criteria)
Excellent- No pain,normal activity
Good- Occasional pain,discomfort
Fair/Poor- Pain,loss of flexion,recurrent
dislocation/subluxation
Worse- Pain increased,displacement more
frequent
Caution
Must avoid overtightening-
Medial instability
Medial patellar arthritis
Patellar fractures
Preexisting Chondromalacia
Details @ http://www.delhiarthroscopy.com/
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
4. Look (Always Compare)
While Patient is standing from front, side, back
and other side then sitting and finally supine
Skin
erythema, ecchymosis
Ms wasting
Alignment
Deformity
Swelling/effusion
8. Feel
Next, find the inferior pole of the patella and
palpate the patella tendon down to its insertion
at the tibial tuberosity
9. Feel
Area of tenderness and probable
swelling
Likely causes
Inferior pole of patella Sinding-Larsen-Johansson syndrome
Patellar tendon Patellar tendinopathy
Patellar rupture
Patellar insertion at tibial tuberosity Osgood-Schlatter-Disease
10. Feel
When you are
at the tibial
tuberosity
palpate with
your finger 1-2
cm medially
If the patient is
tender there,
consider Pes
anserine
bursitis
11. Feel
Have the patient lay supine
Start with palpating:
Medial and lateral femoral and tibial (epi)condyles
& the fibular head:
Medial collateral ligament (MCL) sprain
Lateral collateral ligament (LCL) sprain
Iliotibial (IT) band syndrome
Tibial plateau fracture
Fibular head fracture
13. Feel
Effusion: ‘Milking’
Effusion is assessed by "milking" fluid distally from the
suprapatellar pouch
Place one hand on the supra-patellar pouch. Gently
push down and towards the patella, forcing any fluid
to accumulate in the central part of the joint
Palpate the area adjacent to the patellar tendon for
fluid accumulation
If equivocal, compare
with the other knee
14. Feel
Effusion: Ballottement
A ballotable patella may be
palpated after similar effusion
milking
Place one hand on the supra-
patellar pouch. Gently push
down and towards the patella,
forcing any fluid to accumulate
in the central part of the joint
Gently push down on the
patella with your thumb
If there is a sizable effusion, the
patella will feel as if it is floating
and ‘bounce’ back up when
pushed down
15. Feel
After a trauma there is effusion (hemarthrosis) only if
structures in the joint are involved:
Anterior cruciate or posterior cruciate ligament (ACL, PCL)
injury
Meniscus injury
Patellar dislocation
Intra-articular fracture (e.g. tibial plateau fracture)
Remember: Sole collateral ligament (MCL, LCL) sprains
will not cause an effusion
Causes of non-traumatic effusion:
Osteoarthritis, rheumatoid arthritis, gout, pseudo gout,
Reiter’s syndrome
Infections e.g. gonorrhea
Tumors
16. Feel
Patellofemoral
syndrome (PFPS)
The “J” sign
The patient supine
or seated and the
knee extended from
a flexed position.
Lateral deviation of
the patella can be
observed during the
terminal phase of
extension
17. Feel
Next, clinical tests for patellar mobility and position,
and provocative tests for pain should be performed:
patellar glide
patellar tilt and
patellar grind tests
Positive results on these tests are consistent with the
diagnosis of PFPS
The patellar apprehension test is used to assess for
lateral instability and is positive when pain or
discomfort occurs with lateral translation of the patella
18. Feel
Patellar glide
Assesses patellar
mobility
Displacement of more
than three quadrants
suggests patellar
hypermobility caused
by poor medial
restraints
predisposing for
PFPS
Also, palpate the
19. Feel
Patellar tilt
Positive test = lateral
aspect of patella is
fixed and cannot be
raised to at least
horizontal position
Indicates tight lateral
structures (e.g.: IT-
band) predisposing
for PFPS
20. Feel
Patellar grind test
The patient is in the supine
position with the knee
extended
The examiner displaces the
patella inferiorly into the
trochlear groove
The patient is then asked to
contract the quadriceps
while the examiner
continues to palpate the
patella and provides gentle
resistance to superior
movement of the patella
The test is indicative of
PFPS if pain is produced
21. Feel
Apprehension test
Patient is apprehensive if the examiner tries to
move the patella laterally
Positive after patellar (sub)luxation and in severe
PFPS
22. Move
Test for active & passive ROM while the
patient is supine
Flexion 140°
Extension 0° /-10°
Internal rotation 10°
External rotation 10°
Always compare to the other, “healthy” knee!
23. Special Tests: MCL
Apply valgus stress with
the knee at 0° and bent at
30°
0° tests for MCL as well as
the cruciate ligaments
30° only tests the MCL
Pain speaks for mild
sprain
Pain & laxity speak for
moderate sprain
No fix endpoint speaks for
24. Special Tests: LCL
Apply varus stress with the
knee at 0° and bent at 30°
0° tests for LCL as well as
the cruciate ligaments
30° only tests the LCL
Pain speaks for mild sprain
Pain & laxity speak for
moderate sprain
No fix endpoint speaks for
complete LCL rupture
25. Special Tests: ACL
Lachman test
Patient supine with knee flexed
30°
Pull on the tibia towards you
Anterior drawer test
Patient supine with knee flexed
90°
Stabilize patient’s foot by
sitting on it
Cup your hands around
patient’s knee & draw the tibia
towards you
26. Special Tests: ACL
Lachman & anterior drawer test are positive if
There is increased amount of anterior tibial
translation compared with the opposite leg, and/or
There is no firm end-point
27. Special Tests: ACL
Sensitivity Specificity
Lachman test 85%[1] 94%[1]
Anterior Drawer test 68%[2] 79%[2]
Pivot Shift test 24%[1] 98%[1]
[1] Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis.
J Orthop Sports Phys Ther. 2006 May;36(5):267-88.
[2] Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res. 1995 Aug;(317):2
28. Special Tests: PCL
Posterior drawer test
Stay in the same position as
for the anterior drawer test
Push the tibia posteriorly
If it moves backwards the PCL
is probably damaged
31. Special Tests: Meniscus
Mc Murray
Hold the knee with one hand, place your fingers
along the joint line and flex it to 90°
Hold the foot by the sole with the other hand
32. Special Tests: Meniscus
Mc Murray (cont)
Provide a valgus stress
Rotate the leg externally
Extend the knee
If pain or a ‘click’ is felt = ‘positive McMurray’ for a
medial meniscus tear
33. Special Tests: Meniscus
Mc Murray (cont)
Provide a varus stress
Rotate the leg internally
Extend the knee
If pain or a ‘click’ is felt = ‘positive McMurray’ for a
lateral meniscus tear
34. Special Tests: Meniscus
Apley grind test
The patient lays prone and flexes his/her knee 90°
Place your hand on the patient’s heel and push down
(to compress the menisci between femur & tibia) while
rotating internally & externally
Depending on the area of pain medial or lateral
meniscus tear
35. Special Tests: IT-band
Syndrome
Ober’s Test
The patient lies with the unaffected side down
and the unaffected hip and knee at a 90-degree
angle. If the IT-band is tight, the patient will have
difficulty adducting the leg beyond the midline and
may experience pain at the lateral knee
36. Referred pain
‘Knee pain’ can be referred from the lumbar
spine (e.g. herniated disk) or from a hip or
ankle pathology, so don’t forget to
Do a gross hip and ankle exam
Test the motor strength, sensibility and deep
tendon reflexes of the lower extremities
And always examine both knees!
