OnExam

Inspection

  • Gait:
    • Heel strike, stance, toe off, swing phases
    • Observe for smooth, rhythmic motion, with knee extended only at heel strike of gait cycle
  • Posture in standing:
    • General knee contours
    • Anterior and posterior
      • Genu varum (bowleggedness), genu valgum (knock knees), hyperextension, or flexion contracture
      • Patellar position: patella baja (low rising)/alta (high rising), tilting, rotation, lateral patellar tracking
      • Muscle contour (eg. Quadriceps atrophy)
      • Osgood-Schlatter: a benign yet sometimes painful knee disease in active teenagers. Manifests as a raised and often tender bump inferior to the patient's affected knee(s)
    • Lateral view
      • Observe for hyperextension or flexion contracture
    • Measure leg length with true leg length test
      • Patient supine, measure from ASIS to medial malleolus of ipsilateral leg

Palpation

  • Note areas of pain, swelling, spasm, muscular atrophy, ligamentous laxity, deformity, bogginess or crepitus in the following structures
  • Patient sitting with calfs dangling and knees relaxed

Medial compartment

  • Medial meniscus
  • Medial femoral condyle
  • Adductor tubercle
  • Medial tibial plateau
  • Medial collateral ligament
  • Tibiofemoral joint

Lateral compartment

  • Lateral meniscus
  • Lateral femoral condyle
  • Lateral tibial plateau
  • Head of fibula
  • Lateral collateral ligament
  • Tibiofemoral joint

Patellofemoral compartment

  • Patella
  • Patellar tendon
  • Tibial tuberosity
  • Pre-patellar bursa

Bursae (assess for pain, heat and bogginess/swelling)

  • Suprapatellar bursa (above superior border of patella)
  • Pre-patella bursa (overlying patella)
  • Anserine bursa (posteromedial knee, inserts on medial tibial plateau)
  • Semimembranosus bursa (medial popliteal fossa)

Posterior

  • Popliteal fossa (Baker's cyst) Note: Usually a benign finding
  • Gastrocnemius and soleus muscle

Special Palpation Tests

  • Patellofemoral grind test
  • Suprapatellar pouch (start 10 cm above superior border of patella)
  • Minor Effusions bulge sign
  • Major Effusions ballottement sign and balloon sign
  • Range of Motion

    • Flexion (normal = 135°) “Bend knee”
    • Extension (normal = 10°) “Straighten knee”
    • Internal rotation (normal = 10°) "Swing lower leg toward midline"
    • External rotation (normal = 10°) "Swing lower leg away from midline"

    Special Tests

    Ligamental integrity

    Menisci

    References

    1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
    2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
    3. Cook CE, Hegedus EJ. Orthopedic Physical Examination Tests: An Evidence-Based Approach. New Jersey: Pearson Education; 2008.
    4. Essential Evidence Plus. http://www.essentialevidenceplus.com. 2011. Accessed February 2011.
    5. Filate W, Leung R, Ng D, Sinyor M, eds. Essentials of Clinical Examination Handbook. 5th ed. Toronto, ON. University of Toronto, 2005.
    6. Levy DB, Soft Tissue Knee Injury. Emedicine from WebMD. http://emedicine.medscape.com/article/826792-overview. 2009. Accessed February 2001.
    7. Magee D. Orthopedic Physical Assessment 5th ed. Philadelphia:Saunders; 2008.
    8. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.