complete Knee joint assessment from physiotherapeutic point of view. Includes observation , palpation , assessment, special test, differential diagnosis of knee joint .

1. Pt. Assessment of Knee Joint
By :-
Dr. Taniya verma ( PT)
MPT-musculoskeletal

2. Knee joint
• Tibiofemoral joint
• Modified hinge joint having 3 degree of freedom
• Resting position- 25 degree flexion
• Closed pack position- full extension , lateral rotation of tibia
• Capsular pattern – flexion, extension
• Space between bones filled by menisci – medial (c shape) & lateral menisci (
O shape) ; thick along periphery and thinner along inner margin

3. • Patellofemoral joint
• Thickest layer of cartilage in patella; has 5 facets- superior, inferior,
lateral, medial and odd( frequently affected in patellofemoral
syndrome)
• malalignment of patellar movement can lead to patellofemoral
arthralgia
• Patella function as guide for quads tendon, decreases friction, control
capsular tension in knee, act as bony shield for cartilage of femoral
condyle

5. DEMOGRAPHIC DATA
• Age:
• Gender- conditions prone in
Female- OA ; ACL injuries

6. CHIEF COMPLAINTS
• IN PATIENT’S OWN WORD
• Pain
• Swelling : immediate, delayed
• Stiffness
• Deformity
• Locking
• Giving away
• Limp
• Loss of function

7. HISTORY OF PRESENT ILLNESS
• ONSET OF PAIN
• Date of injuy or when symptoms started
• Gradual/Sudden
• Progression- getting better/getting worse/no change
• LOCATION OF PAIN
• Anterior
• Lateral
• Medial
• posterior

8. Anterior knee pain

9. Lateral knee pain
• IT band friction syndrome
• Biceps femoris tendonitis
• osteoarthritis
• Poplitius tendonitis.

10. Medial knee pain

11. Posterior knee pain

13. Mechanism of present illness-Helps predict
injured structure
• Contact or non contact injury?
• If contact, what part of knee was contacted?
• Anterior blow/ varus force/valgus force
• Was foot of affected knee plated on the ground? (closed vs open chain
injury )
• Bony avulsions- slow developing forces
• Ligament tear- Rapidly developing forces
• MCL injury- Valgus force
• LCL injury- Varus force

15. • ACL INJURY
• Common in wt.bearing, slight flexion and rotation
• Anterior translator force on proximal tibia
• Hyperextension injury

16. • PCL INJURY
• Posterior translation of tibia
• Pretibial trauma( Dashboard trauma)

17. • MENISCAL INJURY
• Twisting force (injury with rotation of tibia) in weight bearing

18. • Any ‘clicking’ or ‘pop’ sound during injury?
• Indicates ligament tear in knee joint
• Any ‘give away’ or ‘catch’?
• Give away= instability
• Catch= (lock) meniscal injury
• Swelling immediate or delayed
• Synovial swelling= takes 8-24 hrs to develop
• Immediate (0–2 hours) (hemarthrosis)= ACL rupture,patellar dislocation
• Delayed (6-24 hrs)(effusion)= meniscus
• No swelling = MCL sprain
• Localized swelling- extracapsular injury
• Generalised swelling- Intracapsular injury

19. • History of type of shoes patient normally uses?- flat/high heels
• Functional ability of the patient?
• Any disability in running, climbing stairs etc
• SPORTS SPECIFIC HISTORY
• Total duration of play
• Total practice/ training session
• Exercise porotocol- warmup/cool down
• Competition.
• Past history
• Any previous injury indicates recurrent injuries around knee
• Was the pain at the same site?
• Similar nature?
• Treatment given previously

20. PAIN ASSESSMENT
• Site of pain – retropatellar?
• Type of pain
• Aching pain = degenerative pain
• Sharp catching pain= mechanical problem
• Arthritic pain= associated with stiffness and eases with movement
• Pain at rest= is not mechanical pain
• Pain during activity= sublaxation, patellar tracking disorder
• Pain after activity= synovitis, tendinitis
• Constant pain irrespective of activity= tumor?
• Pain around knee= contusion, tear of ligament, muscle
• Ask if patient has pain during any specific activity or position or movement.

21. BODY CHART

22. • Aggrevating/ relieving factors
• Severity of pain
• VAS/NPRS

23. OBSERVATIONS
• VIEW FOR OBSERVATIONS
• Standing
• Anterior, posterior and lateral view
• Sitting
• Anterior and lateral view
• Lying
• Supine, side-lying and prone

24. • Patient should be exposed to see knee joint and a joint proximal and
distal to it. ( hip and ankle)
• Key points
• Consent
• Adequate explanation about the necessity of exposure during patient
assessment and its benefits in the treatment
• Confined place and environment to maintain patient’s privacy

25. Observation : anterior view ( standing)
• Knee joint alignment
• Genu valgum /genu varum/windstep deformity
• Children at age of 18-19 months: genu varus which is normal
• Age 3-4 knee attains valgum
• Swelling
• Quadriceps wasting?- disuse atrophy/quadriceps inhibition
• Position of patella
• Squinting of patella- medially facing patella

26. 1.VARUS / 2.VALGUS/ 3.WINDSWEPT DEFORMITY

27. Miserable malalignment syndrome. The patient often presents with medial
parapatellar pain with no localizing findings or images indicating pathology:
A, when viewed from the front, the squinting patella on the right is well
visualized, with both femurs having greater than 50° anteversion;
B, what the patient sees looking down her legs

28. Observation : lateral view ( standing)
• Any discoloration / bruising/ abrasion/scars
• Knee alignment
• Genu recurvatum- hyperextension of knee
• Position of patella
• Patella alta- abnormal high position of patella
(camel sign )
• Patella baja- abnormally low position of patella
• Alignment of other joint- ankle ,hip and spine.
• Lordosis of spine is related to degenerative changes in the knee (
spine-knee syndrome)

29. Camel sign- because of high patella ( one hump), the
infrapatellar fat pad ( second hump) or inflamed infrapatellar
bursae becomes more prominent

30. Observation : Posterior view ( standing)
• Any abnormal swelling?
• Baker’s cyst
• Gastrocnemius- semimembranous bursae
• Popletial artery aneurysm
• Lymphadenopathy
• Soft tissue tumor
• Wasting of hamstring and calf

31. Observation :sitting (lateral and anterior view)
• Observe for position of patella
• Patella should face forward and should rest on the distal end of femur.
• In patella alta= patella rest in anterior surface of femur
• Frogeyes patella or grasshopper patella- patella face upward and outward
away from each other
• Grasshopper eyes or frog eyes is seen in patients whose patellae are
proximally displaced (patella alta) and externally or laterally rotated
(lateral patellar tilt)
• Enlarged tibial tubercle= Osgood schlatter disease.

32. • Fig-pre patellar bursitis.

33. General observation
• Built
• Facial expressions
• Posture
• Guarding/splinting
• Extra devices
• Gait – antalgic/ hand to knee gait in quadriceps weakness

35. • located more distally than
prepatellar bursitis and is often
caused by frequent kneeling in an
upright position

36. Pain and tenderness on the
inside of your knee,
approximately 2 to 3 inches
below the joint, are
common symptoms of pes
anserine bursitis of the
knee.

39. Osgood-Schlatter
disease
• It is an inflammation of the area just below the knee where the tendon
from the kneecap (patellar tendon) attaches to the shinbone (tibia).
• In Osgood-Schlatter disease, the enlarged, inflamed tibial tubercle is nearly
always tender when pressure is applied.

40. PALPATION
• ( WITH VARIOUS ANGLES OF KNEE FLEXION )
• Medio-patellar plica- on medial border of patella
• Jumper’s knee- at the apex of patella ( patellar tendon)
• Patellar tendinitis: palpate distally
• Housemaid’s knee: prepatellar bursitis.
• Patellar retinaculum :can be palpated on either side of patella
• Quadriceps muscle: can be palpated for any strain,wasting or hard
muscle(myositis ossificans)
• MCL: along the medial aspect of knee.
• Pes Anserine bursitis: medial and slight distal to tibial tuberosity.

41. • Temperature: proximal to distal
• Tenderness:
• For soft tissue and bony tenderness.
• Knee flexed at 90’ – examined for tenderness along medial an lateral joint
line.
• Knee extended
• Retropatellar area- by gliding movement of patella between thumb and index finger on
medial and lateral facets, try to palpate undersurface of patella.
• Patellofemoral crepitions.
• Distal pulsations
• Poplitieal pulse

42. Resisted isometric contractions
• Extension of the knee
• Flexion of the knee
• Ankle dorsiflexion
• Ankle plantar flexion

46. Muscle length testing
• Rectus femoris ( ely test )
• Distal hamstring length test

47. Joint play movement
• Backward movement of tibia on femur. ( similar to posterior drawer
test)
• Forward movement of tibia on femur (similar to the anterior drawer
test)
• Medial and lateral translation of tibia on femur.
• Medial and lateral displacement of patella.
• Anteroposterior Movement of Fibula on Tibia

49. Special test
TEST FOR LIGAMENT STABILITY
• One plane medial and lateral instability –valgus and varus stress test
• One plane anterior and posterior instability- posterior sag sign, Lachman test, drawer
sign, active drawer test
• Anteromedial and anterolateral rotary instabilities - Lateral pivot shift maneuver,
Jerk test of hughston; cross over test of Arnold, slocum test
• Posteromedial and posterolateral rotary instabilities - Posteromedial pivot shift
Jakob test (reverse pivot shift maneuver), Hughston posterolateral and posteromedial
drawer sign .
• Tests for meniscus injury- McMurray test , Apley’s test.
• Plica test - Mediopatellar plica test
• Tests for patellofemoral dysfunction - Clarke’s sign ; McConnell test for
chondromalacia patella
• Tests for swelling -Brush, stroke, or bulge test ; Fluctuation test ; Patellar tap test
(ballotable patella)
• Test for patellar dislocation- fairbank apprehension test

50. Valgus and Varus stress test

51. Posterior sag sign

52. Lachman test

53. Drawer sign

54. Active drawer test

55. Anterolateral instability
• Lateral pivot shift test • Jerk test of hughston

56. Cross over test of Arnold slocum test

57. Jackob test (reverse pivot shift maneuver)

58. Postero-medial pivot shift test

59. Hughston’s posteromedial and posterolateral
drawer test

60. Meniscus injury
• McMurray test • Apley’s test

61. Mediopatellar plica test (Mital-hayden test)

62. CLARKE’S SIGN
• PURPOSE -To assess for patellofemoral dysfunction.
• PATIENT POSITION - supine with the knee extended.
• EXAMINER POSITION -The examiner stands adjacent to the patient’s knee.
• TEST PROCEDURE
• The unaffected leg is tested first. The thenar web space of one of the examiner’s hands
is placed slightly proximal to the upper pole or base of the patella. The examiner presses
down several times with increasing force until pain is produced on the proximal aspect of
the patella. The patient then is asked to contract the quadriceps muscles after the
examiner pushes down. The test is repeated with the painful knee, and the amounts of
pressure that cause pain are compared.
• INDICATIONS OF A POSITIVE TEST A positive test result is indicated if the test causes
retro patellar pain and the patient cannot hold a contraction. If the patient can complete
and maintain the contraction without pain, the test result is considered negative, as long
as the same test on the unaffected leg does not cause pain.
• CAUTIONS • Because a positive test result can be obtained on anyone if sufficient
pressure is applied to the patella, the amount of pressure applied must be carefully
controlled and compared with the opposite side. This is best done by repeating the
procedure several times, increasing the pressure each time and comparing the results
with those on the unaffected side.
• • To test different parts of the patella, the knee may be tested in 30°, 60°, and 90° of
flexion and in full extension.

63. MCCONNELL TEST FOR CHONDROMALACIA
PATELLA
• The unaffected leg is tested first. After the examiner has positioned the knee at 120°, 90°, 60°,
30°, and 0° (full extension), the patient performs isometric quadriceps contractions with the
femur laterally rotated, with each contraction held for 10 seconds. If pain is produced during any
of the contractions, the patient’s leg is passively returned to full extension. The leg then is fully
supported on the examiner’s knee, and the examiner pushes the patella medially. The medial
glide is maintained while the knee is returned to the painful angle, and the patient performs an
isometric contraction again, with the patella held medially. The two legs are compared.
• If the pain is decreased when the patella is held medially, the pain is patellofemoral in origin.

64. BRUSH, STROKE, OR BULGE TEST for effusion
• PURPOSE - To assess minimal effusion in the knee.
• PATIENT POSITION -The patient lies supine.
• EXAMINER POSITION - The examiner is positioned adjacent to the test knee.
• TEST PROCEDURE
• The examiner places one hand over the anteromedial tibia. Starting just below the joint line on
the medial side of the patella and using the palm and fingers, the examiner strokes proximally
toward the patient’s hip, as far as the suprapatellar pouch, two or three times. With the opposite
hand, the examiner strokes down the lateral side of the patella.
• INDICATIONS OF A POSITIVE TEST A positive test result is indicated when a wave of fluid passes
along the medial side of the joint and bulges just below the medial distal portion or border of the
patella during the down stroke. The wave of fluid may take up to 2 seconds to appear.
• CLINICAL NOTES • Also called the wipe test, this test assesses minimal effusion. • Normally, the
knee contains 1 to 7 ml of synovial fluid. This test can show as little as 4 to 8 ml of extra fluid
within the knee.

65. Fluctuation test
• PATIENT POSITION -supine.
• EXAMINER POSITION -adjacent to the test knee.
• TEST PROCEDURE - The examiner places the palm of one hand over the
suprapatellar pouch and the palm of the other hand anterior to the joint at
the joint line, with the thumb and index finger just beyond the margins of
the patella.Pressing down with one hand and then the other, the examiner
may feel the synovial fluid fluctuate under the hands and move from one
hand to the other.
• INDICATIONS OF A POSITIVE TEST- Increased fluctuation of fluid in the
knee compared to the contralateral knee indicates significant effusion.

66. Patellar tap test
• PATIENT POSITION -The patient lies supine.
• EXAMINER POSITION -The examiner is positioned adjacent to the
test knee.
• TEST PROCEDURE - With the patient’s knee extended or flexed to
discomfort, the examiner applies a slight tap or pressure over the
patella.
• INDICATIONS OF A POSITIVE TEST- When the tap is applied, the
patella should be felt to fl oat; this is sometimes called the “dancing
patella” sign.

67. FAIRBANK’S APPREHENSION TEST
• PURPOSE -To assess for dislocation of the patella.
SUSPECTED INJURY Dislocation or subluxation of the patella
• PATIENT POSITION
-The patient lies supine with the quadriceps muscles relaxed and the knee
flexed to 30º over the examiner’s leg.
• EXAMINER POSITION - The examiner sits directly adjacent to the test knee.
• TEST PROCEDURE - The unaffected leg is tested first. The examiner’s
thumbs are placed on the medial border of the patella, and the fingers are
placed on the lateral aspect of the patient’s knee. The examiner carefully
and slowly pushes the patella laterally with the thumbs. The two legs are
compared.
• INDICATIONS OF A POSITIVE TEST If the patient feels that the patella is
going to dislocate, he or she will contract the quadriceps muscles to bring
the patella “back into line.” This action indicates a positive test result. The
patient also will have an apprehensive look.

68. Differential diagnosis by location
•ANTERIOR- patellofemoral syndrome, bursitis, Osgood
schalatter’s disease, patellar tendinitis, patellar fractur
•MEDIAL- meniscus, MCL, OA, pes anserine bursitis
•LATERAL- Meniscus, LCL, OA, iliotibal friction band
syndrome, Fibular head dysfunction
•POSTERIOR- Hamstring injury, Baker’s cyst,
Neurovascular injury ( popliteal artery or nerve. )

72. Differential diagnosis by location
anterior knee pain
Condition Typical finding
Tibial apophysitis Tendar and swollen tibial tuberosity
Resisted active extension and passive hyperflexion of
knee painful
Patellar tendonitis Tender patellar tendon; resisted knee extension
painful
Slipped capital femoral epiphysis Displacement of epiphysis of femoral head in
radiographs; passive hip IR painful
PFPS Slight effusion along with patellar crepitus on ROM;
reproduction of patient’s pain by applying direct
pressure at anterior aspect of patella
ACL injury Positive anterior drawers test; Lachman test

73. Medial knee pain
Condition Typical findings
Medial plica syndrome Tenderness near medial patellar retinaculum that
worsen with knee flexion
MCL tear Laxity; regional pain with valgus stress testing
Meniscal tear Tenderness over medial joint line; positive McMurry
test
OA Regional medial knee pain; tender joint line;
decreased ROM; degenerative changes in radiograph
Pes anserine bursitis Tenderness 2-4 cm below medial joint line; painful
resisted knee flexion in prone position
Medial collateral ligament sprain Point tenderness at medial joint line; positive valgus
stress test

74. Lateral knee pain
Condition typical findings
Iliotibial band tendonitis Tenderness at lateral epicondyle of femur approx. 3
cm proximal to the joint line
Positive noble test
Lateral collateral ligament sprain Point tenderness at lateral joint line; positive varus
stress testing

75. Posterior knee pain
Conditions Typical findings
Popliteal cyst Palpable fullness at medial aspect
of popletial area, at or near the
origin of medial head of
gastrocnemius
Hamstring tendonitis Localized tenderness over medial
hamstring tendon insertion

76. Comparison of clinical features of 3 common
cause of anterior knee pain
Signs Patellofemoral pain Patellar tendinopathy Fat pad impingement
Onset Running ( esp. downhill)
Steps/hills
Wt. bearing act. involving
knee flexion
Act. Involving
jumping/changing
directions
Often but not always,
sudden onset with
hyperextension injury
Pain Non specific/vague
Med./lat./infrapatellar
Increased by act. That
load PFJ
Around inferior pole of
patella
Inc. by jumping & early to
mid squat
Around inferior pole of
patella
Inc. by prolonged
standing, stairs, knee
extension
Inspection Generally normal
Or VMO wasting
Generally quadriceps
wasting
Puffiness may be
apparent around tendon
which may make pole of
patella appear to be
displaced posteriorly
Swelling May have small effusions, Rare, tendon may be May have a puffy

77. Signs Patellofemoral pain Patellar tendinopathy Fat pad impingement
Clicks Occasional No No
Crepitus Occasionally under patella No No
Giving way Occasional Occasionally due to
quadriceps inhibition
No
Knee ROM Usually normal
May be decreased
Usually normal,
No pain with overpressure
Active extension may be
painful in acute fat pad
impingement
Passive overpressure into ext.
is painful
PFJ movement May be restricted n any
direction ( commonly medial
glide due to tight lateral
structure)
May have normal PFJ
biomechanics
Normal or posteriorly
displaced inferior pole of
patella.
Functional testing Squats, stairs may aggravates
PFJ taping should decrease
pain
Decline squats aggravates
pain
PFJ taping has less effect
Aggravates by squats
PFJ taping should decrease
pain if inferior pole of patella
is tilted up.

78. References :-
• David J. Magee-orthopedic physical assessment 5th edition
• Peter brunker and karim khan- clinical sports medicine .3rd edition
• Muscle Function Testing : Vladimir Janda
• Measurement of Joint Motion A Guide to Goniometry : Cynthia C
norkin ( third edition )