PHYSICAL EXAMINATION

OF THE KNEE
Hermansyah, MD

RSU Lubuk Basung

RSU. Basung, Kabupaten Agam
SUMATERA BARAT
Anatomyy Review

z Bony Anatomy
z Lower Leg
z Tibia
z Fibula
z Upper Leg
z Femur
z Patella
Anatomyy Review
z Lower Leg Musculature
z Anterior
z Tibialis Anterior
z Medial
z Tom Dick and Harry
Tom,
z Tibialis Posterior
z Extensor Digitorum
Longus
z Extensor Hallicus Longus
z Lateral
z Peroneals
z Posterior
z Gastrocnemius
z Soleus
z Tibialis Anterior
Anatomyy Review
z Thigh Musculature
z Anterior
z Quadriceps Femoris
z Vastus Lateralis
z Vastus Medialis
z Vastus Intermedius
z Rectus Femoris
z Posterior
z Biceps Femoris
z Long Head
z Short Head
z Semi tendonosis
Semi-tendonosis
z Semi-membranosis
z Gracilis
Anatomyy Review

z Ligaments
z Medial
Collateral
z Lateral
Collateral
z Anterior
Cruciate
z P t i
Posterior
Cruciate
Anatomyy Review

z Cartilage
z Medial Meniscus
z Lateral Meniscus
z Articular Cartilage
Anatomyy Review

z Joint Capsule
Anatomyy Review

z Bursae
Anatomyy Review

z Nerve Supply
z Blood Supply
Knee Evaluation (History)
Anamnesis

Mechanism of injury
z Type of activity
z T
Type off trauma
t
(Contact?)
Knee Evaluation (History)
I. Direction of injury force
Hyperextension Injury
Anterior Cruciate Ligament Tear
Direct blow to lateral side of knee (Valgus Stress)
Medial Collateral Ligament Injury
Direct blow to medial side of knee (Varus Stress)
Lateral Collateral Ligament Injury
Direct blow to anterior knee (e(e.g.
g knee hits dashboard)
Posterior Cruciate Ligament injury
Twisting Injury
Anterior Cruciate Ligament Tear
Meniscus Injury
Patella subluxation or Patella dislocation
Quick stop or sharp cut
Anterior Cruciate Ligament Tear
Knee Evaluation (Observation)
z Observation
z Walking,
W lki h
half
lf squatting,
tti going
i up and
dddown stairs
t i
z Swelling, ecchymosis,
z Leg alignment
z Genu valgum
g and g
genu varum
z Hyperextension and hyperflexion
z Patella alta and baja
Knee Evaluation

z Q-Angle
Q Angle
Knee Evaluation (Observation)
z Tibial torsion
z An angle that
measures less
th 15 d
than degrees
is an indication
of tibial torsion
Knee Evaluation (Observation)
z Knee Symmetry or
Asymmetry
z Do the knees look
symmetrical? Is there
obvious swelling?
Atrophy?
z Leg Length Discrepancy
z Anatomical or functional
z Anatomical differences
can potentially cause
problems in all weight
bearing joints
z Functional differences
can be
b caused db
by pelvic
l i
rotations or mal-
alignment of the spine
Knee Evaluation (Palpation)
z Palpation
p – Bonyy z Tibial tuberosity
z Medial tibial plateau z Superior and inferior patella
borders (base and apex)
z Medial femoral condyle
z Around the pperiphery
p y of the
z Adductor tubercle
knee relaxed, in full flexion
z Gerdy’s tubercle and extension
z Lateral tibial plateau
z Lateral femoral condyle
z Lateral epicondyle
z Head of fibula
Knee Evaluation (Palpation)
z Palpation
p - Soft z Medial and lateral collateral
ligaments
Tissue
z Pes anserine
z Vastus medialis
z Vastus lateralis z Medial/lateral jjoint capsule
p
z Vastus intermedius z Semitendinosus
z Rectus femoris z Semimembranosus
z Quadriceps and patellar z Gastrocnemius
tendon z Popliteus
z Sartorius z Biceps Femoris
z Medial patellar plica
z Anterior joint capsule
z Iliotibial Band
z Arcuate complex
Knee Evaluation (Palpation)

z Palpation of Swelling
z Intra vs. extracapsular swelling
z Intracapsular
p mayy be referred to as jjoint effusion
z Swelling w/in the joint that is caused by synovial
fluid and blood is a hemarthrosis
z S
Sweep maneuver
z Ballotable patella - sign of joint effusion
z Extracapsular swelling tends to localize over the
injured structure
z May ultimately migrate down to foot and ankle
Knee Evaluation (Special Tests)
z Active / Passive Range
g of Motion
z Flexion – 0o to 135o
z Extension – 130o to 0o
z Manual Muscle Testing
z Five Point grading system
z 5 = Complete ROM against gravity, with full resistance
z 4 = Complete ROM against gravity, with some resistance
z 3 = Complete ROM against gravity, with no resistance
z 2 = Complete ROM, with gravity omitted
z 1 = Some muscle contractility with no joint motion
z 0 = No muscle contractility
z Knee Flexion / Extension
z Internal Rotation / External Rotation
Knee Evaluation (Palpation)

1
1. Knee effusion with obscured landmarks
Ballottable Patella Sign Knee Bulge
Sign
Knee effusion

z Cross fluctuation
Cross-fluctuation
Left hand compress and empty supra
patellar pouch
pouch, while the right hand
straddles the front joint beow patella
z The
Th patellar
t ll h
hollow
ll
The hollow disappear when knee in
flexion
Palpation n of patella

z Patellar Apprehension Test

Knee Evaluation (Special Tests)
z Joint Instability
z A t i C
Anterior Cruciate
i t Li
Ligamentt (L
(Lachman’s
h ’ TTest)
t)
z Will not force knee into painful flexion immediately after injury
z Reduces hamstring involvement
z At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the
femur
z A positive test indicates damage to the ACL
Knee Evaluation (Special Tests)
z Joint Instabilityy
z Anterior Cruciate Ligament (Ant. Drawer)
z Drawer test at 90 degrees of flexion
z Tibia sliding
Tibi lidi fforwardd ffrom under
d ththe ffemur iis considered
id d a positive
iti
sign (ACL)
z Should be performed w/ knee internally and externally to test
integrity of joint capsule
ACL Ruptured
p
Knee Evaluation
z Other ACL Stability Tests
z Pivot Shift Test
z Used to determine
anterolateral rotary instability
z Position starts w/ knee
extended and leg internally
rotated
z The thigh and knee are then
flexed w/ a valgus stress
applied to the knee
z Reduction of the tibial
plateau (p
p (producingg a clunk))
is a positive sign
Knee Evaluation (Special Tests)

z Other Posterior
Cruciate Ligament
Tests
z Posterior Drawer Test
z Knee is flexed at 90
degrees and a
posterior force is
applied to determine
translation posteriorly
z Positive sign
indicates a PCL
deficient knee
z Tes PCL Sulcus
z Joint Stability Tests
z Posterior Cruciate Ligament Stability
z Posterior Sag Test (Godfrey’s test)
z Athlete is supine w/ both knees flexed to 90 degrees
z Lateral observation is required to determine extent of posterior sag while
comparing bilaterally
PCL Ruptured
p
Knee Evaluation (Special Tests)

z Joint Instability (Valgus test)

z Medial Collateral Ligament Instability
MCL Ruptured
p
Knee Evaluation (Special Tests)

z Joint Instability (Varus Test)

z Lateral Collateral Ligament Instability
LCL Ruptured
p
Grading
g Instability
y
Knee Evaluation (Special Tests)

z Meniscal Pathology
z McMurray’s Meniscal Test
z Used to determine displaceable meniscal tear
z Leg is moved into flexion and extension while knee is internally and
externally rotated in conjunction w/ valgus and varus stressing
z A positive test is found w/ clicking and popping response

Medial Meniscus Testing

Knee Evaluation (Special Tests)

z McMurray Test Continued

Lateral Meniscus Test

Knee Evaluation (Special Tests)
z Meniscal Pathology
z Apley’s Compression Test
z Hard downward pressure
is applied w/ rotation
z Pain indicates a
meniscal injury
z Apley’s Distraction Test
z Traction is applied w/
rotation
z Pain will occur if there is
damage to the capsule
or ligaments
z No pain will occur if it is
meniscal
z Cabot's manoeuvre
z The heel is placed on the tibial crest of the opposite
leg.
z The knee is gradually flexed
flexed, while the heel runs
along the tibial crest.
z This movement may produce lateral pain, when the
knee is in 90° of flexion with the heel resting on the
other leg (Cabot's position).
z The lateral compartment
p is distracted by
yppressure
on the medial side of the knee; this, too, may be
painful.