PHYSICAL EXAMINATION OF THE KNEE

Hermansyah, MD

RSU. RSU Lubuk Basung Kabupaten Agam Basung, SUMATERA BARAT

Anatomy Review y
Bony Anatomy
Lower Leg
Tibia Fibula

Upper Leg
Femur

Patella

Anatomy Review y
Lower Leg Musculature
Anterior
Tibialis Anterior

Medial
Tom, Tom Dick and Harry
Tibialis Posterior Extensor Digitorum Longus Extensor Hallicus Longus

Lateral
Peroneals

Posterior
Gastrocnemius Soleus Tibialis Anterior

Anatomy Review y
Thigh Musculature
Anterior
Quadriceps Femoris
Vastus Lateralis Vastus Medialis Vastus Intermedius Rectus Femoris

Posterior
Biceps Femoris
Long Head Short Head

Semi tendonosis Semi-tendonosis Semi-membranosis Gracilis

Anatomy Review y Ligaments Medial Collateral Lateral Collateral Anterior Cruciate Posterior P t i Cruciate .

Anatomy Review y Cartilage Medial Meniscus Lateral Meniscus Articular Cartilage .

Anatomy Review y Joint Capsule .

Anatomy Review y Bursae .

Anatomy Review y Nerve Supply Blood Supply .

Knee Evaluation (History) Anamnesis Mechanism of injury Type of activity Type of trauma T ft (Contact?) .

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 .g.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 g knee hits dashboard) (e.

Knee Evaluation (Observation) Observation Walking. Leg alignment Genu valgum and g g genu varum Hyperextension and hyperflexion Patella alta and baja . ecchymosis. h lf squatting. going up and d W lki half tti i d down stairs t i Swelling.

Knee Evaluation Q Angle Q-Angle .

Knee Evaluation (Observation) Tibial torsion An angle that measures less than th 15 d degrees is an indication of tibial torsion .

Knee Evaluation (Observation) Knee Symmetry or Asymmetry Do the knees look symmetrical? Is there obvious swelling? Atrophy? Leg Length Discrepancy Anatomical or functional Anatomical differences can potentially cause problems in all weight bearing joints Functional differences can b caused b pelvic be d by l i rotations or malalignment of the spine .

in full flexion and extension .Knee Evaluation (Palpation) Palpation – Bony p y Medial tibial plateau Medial femoral condyle Adductor tubercle Gerdy’s tubercle Lateral tibial plateau Lateral femoral condyle Lateral epicondyle Head of fibula Tibial tuberosity Superior and inferior patella borders (base and apex) Around the periphery of the p p y knee relaxed.

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Knee Evaluation (Palpation) Palpation .Soft p Tissue Vastus medialis Vastus lateralis Vastus intermedius Rectus femoris Quadriceps and patellar tendon Sartorius Medial patellar plica Anterior joint capsule Iliotibial Band Arcuate complex Medial and lateral collateral ligaments Pes anserine Medial/lateral joint capsule j p Semitendinosus Semimembranosus Gastrocnemius Popliteus Biceps Femoris .

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sign of joint effusion Extracapsular swelling tends to localize over the injured structure May ultimately migrate down to foot and ankle .Knee Evaluation (Palpation) Palpation of Swelling Intra vs. extracapsular swelling Intracapsular may be referred to as j p y joint effusion Swelling w/in the joint that is caused by synovial fluid and blood is a hemarthrosis Sweep maneuver S Ballotable patella .

with full resistance 4 = Complete ROM against gravity.Knee Evaluation (Special Tests) Active / Passive Range of Motion g Flexion – 0o to 135o Extension – 130o to 0o Manual Muscle Testing Five Point grading system 5 = Complete ROM against gravity. with no resistance 2 = Complete ROM. with some resistance 3 = Complete ROM against gravity. with gravity omitted 1 = Some muscle contractility with no joint motion 0 = No muscle contractility Knee Flexion / Extension Internal Rotation / External Rotation .

1 Knee effusion with obscured landmarks Ballottable Patella Sign Knee Bulge Sign .Knee Evaluation (Palpation) 1.

straddles the front joint beow patella The t ll hollow Th patellar h ll The hollow disappear when knee in flexion .Knee effusion Cross fluctuation Cross-fluctuation Left hand compress and empty supra patellar pouch while the right hand pouch.

Palpation n of patella Patellar Apprehension Test .

Knee Evaluation (Special Tests) Joint Instability Anterior Cruciate Ligament (L h A t i C i t Li t (Lachman’s T t) ’ Test) Will not force knee into painful flexion immediately after injury Reduces hamstring involvement At 30 degrees of flexion an attempt is made to translate the tibia anteriorly on the femur A positive test indicates damage to the ACL .

Knee Evaluation (Special Tests) Joint Instability y Anterior Cruciate Ligament (Ant. Drawer) Drawer test at 90 degrees of flexion Tibia lidi forward f Tibi sliding f d from under th f d the femur i considered a positive is id d iti sign (ACL) Should be performed w/ knee internally and externally to test integrity of joint capsule .

ACL Ruptured p .

Knee Evaluation Other ACL Stability Tests Pivot Shift Test Used to determine anterolateral rotary instability Position starts w/ knee extended and leg internally rotated The thigh and knee are then flexed w/ a valgus stress applied to the knee Reduction of the tibial p plateau (p (producing a clunk) g ) is a positive sign .

Knee Evaluation (Special Tests) Other Posterior Cruciate Ligament Tests Posterior Drawer Test Knee is flexed at 90 degrees and a posterior force is applied to determine translation posteriorly Positive sign indicates a PCL deficient knee .

Tes PCL Sulcus .

Joint Stability Tests Posterior Cruciate Ligament Stability Posterior Sag Test (Godfrey’s test) Athlete is supine w/ both knees flexed to 90 degrees Lateral observation is required to determine extent of posterior sag while comparing bilaterally .

PCL Ruptured p .

Knee Evaluation (Special Tests) Joint Instability (Valgus test) Medial Collateral Ligament Instability .

MCL Ruptured p .

Knee Evaluation (Special Tests) Joint Instability (Varus Test) Lateral Collateral Ligament Instability .

LCL Ruptured p .

Grading Instability g y .

Knee Evaluation (Special Tests) Meniscal Pathology McMurray’s Meniscal Test Used to determine displaceable meniscal tear Leg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressing A positive test is found w/ clicking and popping response Medial Meniscus Testing .

Knee Evaluation (Special Tests) McMurray Test Continued Lateral Meniscus Test .

Knee Evaluation (Special Tests) Meniscal Pathology Apley’s Compression Test Hard downward pressure is applied w/ rotation Pain indicates a meniscal injury Apley’s Distraction Test Traction is applied w/ rotation Pain will occur if there is damage to the capsule or ligaments No pain will occur if it is meniscal .

The lateral compartment is distracted by p p y pressure on the medial side of the knee. along the tibial crest. The knee is gradually flexed while the heel runs flexed. when the knee is in 90° of flexion with the heel resting on the other leg (Cabot's position). This movement may produce lateral pain. this.Cabot's manoeuvre The heel is placed on the tibial crest of the opposite leg. may be painful. too. .