Comprehensive Knee Examination, Cheat Sheet of Medicine

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Knee Exam:

■ Examination of Knee: WIPER

■ Explain examination: Today I need to examine your

knee joint, this will involve looking, feeling and

moving the joint. Check understanding & gain

consent: “Does everything I’ve said make sense? Are

you happy for me to examine your knee joint?

■ Expose patient’s legs – ideally the patient should be

wearing shorts, Position the patient standing upright ,

inspect for mobility aids & adaptations – walking

stick / wheelchair / knee brace. Ask if patient has any

pain anywhere before you begin!

■ Get the patient to squat to help localise the precise point of pain. Ask

the patient squat down two see two important piece of information:

Range of motion of the knee to 135 degrees and Power.

■ Assess fixed flexion deformity by squatting down and looking at each

knee from the side. A space under the knee will be visible if there is

permanent flexion deformity arthritis. The commonest knee mal

alignment that can be presented with swollen knee is flexion contracture.

Anteriorly

■ Scars – previous surgery / trauma ( midline scar : indicates TKR, Small

scars around : Arthroscopy)

■ Swellings/Erythema – effusions / inflammatory arthropathy / septic

arthritis / gout (First noticed by loss of the Medial & Lateral peripatellar

groove- early sign of effusion), Also swelling can be seen in Supra-patellar

pouch.

■ Asymmetry

■ (^) Valgus mal-alignment : ‘ Knock knee’. Valgus deformity is often related to rheumatoid arthritis. ■ (^) Varus mal alignment : called the ‘Bow leg”. Varus deformity is often related to osteoarthritis ( Gode ik duje de vairy ban jande a in Varus / Bow/Osteo) ■ (^) Quadriceps wasting – suggests chronic inflammation / reduced mobility- The commonest muscle atrophy around the knee is Quadriceps. So any patient with knee pain, please take a look to the Quadriceps muscle and compare side by side with the other leg to see if the muscle bulk is less than the other side. This begins quite soon after knee abnormalities lead to disuse of the muscle ). ■ Then ask the patient to stand up where we can look for the knee to back to zero degree.

Feel: ■ (^) Temperature : The knee is usually cooler than the surrounding structure. So start above the knee (feel with the back of the hand), then over the knee and then below it. Always compare with the other side. ■ (^) Put the knee in slight flexion position to do the palpation on the right way. You should finish palpating one knee completely before going to the other knee to compare. Also usually we start from the superior aspect of the knee going down to perform the palpation of the knee structures. ■ (^) Start palpation standing in a position where you are looking at the leg and your back is facing the patient. Use the thumbs of both hands palpate the Quadriceps. Then move to suprapatellar pouch(bursa) synovial thickening, a hallmark of chronic arthritis, is most marked just above the patella—it feels warm, boggy, rubbery and has no fluid thrill. Then to the insertion of Quadriceps (into the patella).

■ Move for posterior palpation of the knee looking for Baker’s

Cyst. Also we can feel the popliteal pulse. Also with the

same position (knee slightly flexed and you sitting lateral to

the examining part) palpate downwards the calf muscles

and compare both side.

■ Feel the swelling at the knee. This is done by two tests:

• (^) Patellar tap test (for large effusions): with the rounded web between the thumb and the index finger push the supra-patellar pouch downwards. With your other hand push the patella downwards. The sign is positive if the patella is felt to sink and then comes to rest with a tap as it touches the underlying femur.
• (^) Bulge test (fluid wave test or milking test): Use your left hand to compress the suprapatellar pouch while you run the fingers of your right hand along the groove beside the patella on one side and then the other. A bulging along the groove due to a fluid wave, on the side

■ Patellar Apprehension Test evaluates patella

subluxation and dislocation. The patient is positioned

supine, with the knee flexed between 0° and 30°. The

examiner firmly pushes the patella in a lateral

direction. The patient, who knows and apprehends the

dislocation that will be produced by this maneuver, will

stop the examiner. Results are recorded as + or 0.

■ Pathophysiology: Between 0° and 30° of flexion, the

patella is at its highest point in the trochlea. Pressure

from the medial side will push the patella in a lateral

direction, causing it to dislocate from the trochlear

groove. This will cause not only pain, but apprehension

on the part of the patient.

Patellar Tendinitis Test

Testing stability and ligaments of the knee: Cruciate ligament testing: ■ (^) Anterior Drawer test : This tests the anterior cruciate ligament ■ (^) Put the knee in flexion 90 degrees. Inspect for evidence of posterior sag as this can give a false +ve anterior drawer sign. ■ (^) Sit on the patient’s foot to stabilize. Put the left and right thumbs on the tibia. Pull forward to see if you can displace the tibia anteriorly. ■ (^) Push the tibia posteriorly – significant movement suggests posterior cruciate laxity / rupture. Again, movement of more than 5–10° is abnormal.