Musculoskeletal Knee Examination Script 2020

Score sheet – Were the Standard Examination Competencies (SEC) demonstrated? NO YES

1. Introduction Commence at: 0:00 (30s duration)

− Performs hand wash/hand rub.
− Introduces self – “My name is…. I am a first year medical student from UQ.”
− Explains purpose – “Today we are going to examine your knees. This will
involve…”
− Obtains consent – “Does that sound okay with you?”

2. Look (Inspection) Commence at: 0:30 (60s duration)

With patient standing:
− Ensure adequate exposure, with shoes removed.
− Look at anterior, lateral and posterior aspect of patient’s legs.
− Look for deformities (genu valgum or varum, genu recurvatum), muscle bulk,
popliteal fossa masses, malposition of the feet and arches.
− Report as you see: e.g. “Upon inspection…”
− “There is normal symmetrical posture of the hips, knees and feet.”
− “There are no deformities, spasms or wasting.”
− “There are no scars, redness or swelling.”

− Assess the patient’s gait - ask patient to walk across room and then walk back.
− Report findings e.g. “the patient’s gait is normal.”

3. Squat tests (Screening) Commence at: 1:30 (60s duration)

− Ask patient if they are able to squat.
− Face patient and hold both of their hands for support.
− Ask patient to perform a squat with feet parallel to each other (hip rotation
neutral).

Ege’s Test (Medial and Lateral Menisci tests):

− Ask patient to perform a squat with feet turned outwards (hip externally rotated).
− Ask patient to perform a squat with feet turned inwards (hip internally rotated).
− Ask patient if there was any pain and where it was located.
− Report findings e.g. “Squat testing/Ege’s test was normal.”

1
4. Feel (Palpation) Commence at 2:30 (120s duration)
− Ask patient to lie supine on examination bed.
− Explain to patient “I’m now going to feel around your knee and assess
movement”
− Encourage patient to report any tenderness “Let me know if anything I do is
painful and I will stop.”

− Feel temperature over quadriceps, patella, tibia or over any red areas.
− Examine both knees and compare findings.

Palpate with knee in extension (straight):

− Quadriceps, superior pole (base) of patella, insertion of quadriceps
tendon, patella body for prepatellar bursitis, inferior pole of patella and
patella tendon, tibial tuberosity (tenderness of Osgood Schlatter’s
disease).
− Repeat on opposite knee

Palpate knee in 30-45 degrees flexion (with a pillow under the knee):
− Sides of patella (patello-femoral pain syndrome, patellofemoral ligament
rupture), femoral condyles and joint line (medial and lateral depressions beside
patellar tendon), follow lateral and medial lines (meniscal tears), fibular head.
− Repeat on opposite knee

Palpate popliteal fossa:

− Whilst gripping the knee with both hands, feel the popliteal fossa with your
fingertips.
− Feel pulse, Baker’s cyst, hamstring tendons and insertion around lateral and
medial aspects of joint line.
− Repeat on opposite knee

− Ask patient, “Was there any tenderness?”

− Report findings e.g. “Muscle bulk was normal and symmetrical. There was no
tenderness of the muscles, patella or joint line. There was no evidence of a
Baker’s cyst.”

5. Effusion Tests Commence at: 4:30 (60s duration)

SWIPE/BULGE TEST (Small Effusion 5-10mL):
− Empty suprapatellar bursa with 2-3 sweeping motions.
− Firmly pressing with your full hand and sweeping from starting positing (near
mid anterior quadriceps) moving distally to superior border of patella.
− Swipe along the sulcus lateral to the patella, while looking for a ‘wave’
filling the medial sulcus (this theoretically works on both sulci, but waves
are best seen on medial side).
− Repeat on opposite side
− Report findings e.g. “Swipe test is negative.”

PATELLAR TAP/BALLOTMENT TEST (Large Effusion 10-20mL):

− Compress suprapatellar bursa with left hand.

2
 − Firmly press downward (posteriorly) on the patella with several fingers.
− Determine if there is movement onto condyles below or if the patella is in
immediate contact with the patella.
− Repeat on opposite side.
− Report findings e.g. “Patellar tap test is negative.”

6. Patellar Apprehension Test Commence at: 5:30 (30s duration)

− Fully extend knee (straighten leg).
− Ask patient to report any pain.
− Push patella laterally away from the midline.
− Look at patient’s face, during lateral pressure away from the midline, to gauge
patient’s response.
− A grimace or comment of discomfort from the patient is positive test.
− Repeat on opposite side.
− Report findings e.g. “Patellar apprehension testing is negative.”

7. Move – Active then Passive Commence at: 6:00 (60s duration)

− Ask patient to report any pain.
− Ask patient to flex their knee fully (135-140 degrees, feet close to body) then
extend fully (zero degrees, feet away from body, legs straight).
− Passively flex knee fully and extend fully with hand on knee to feel for crepitus.
− Test for hyperextension by lifting the heel off the bed.
− Repeat on opposite side.
− Report findings e.g. “There is normal active and passive range of movement, with
no tenderness and no crepitus.”

8. Sag Sign (Posterior Cruciate Ligament) Commence at: 7:00 (30s duration)
− Ask patient to bend both knees (90 degrees flexion), with feet on bed.
− Feet and knees need to be aligned and adducted together.
− Inspect laterally for differences in position of the tibial plateaus.
− Report findings e.g. “There is no evidence of sag sign.”

9. Anterior and Posterior Draw Tests Commence at: 7:30 (60s duration)
− Warn patient that you will sit across their foot to prevent it sliding.
− Keep knees in 90 degrees, wrap both hands around the tibial plateau.
− Perform anterior/posterior draw tests on both knees and compare findings.

ANTERIOR DRAW TEST (Anterior Cruciate Ligament - ACL):

− Draw tibia anteriorly (towards you).
− Note amount of movement from zero point:
o Grade 1: 0-5 mm movement.
o Grade 2: 5-10 mm movement.
o Grade 3: 10 plus mm movement.
− Feel for “end feel” – rubbery (rupture) or firm (intact).

POSTERIOR DRAW TEST (Posterior Cruciate Ligament – PCL):

3
 − Push tibia posteriorly (away from you).
− Note again amount of movement and “end feel.”

− Report findings e.g. “Anterior and posterior draw tests are negative.”

10. Lachman’s Test (Anterior Cruciate Ligament) Commence at: 8:30 (60s duration)
− Support knee on one pillow, aiming for around 30 degrees of flexion.
− Control distal femur with one hand, draw tibial plateau with other hand.
− Draw back and forth along direction of joint line (anterior-posterior).
− Note again amount of movement and “end feel.”
− Repeat on opposite side.
− Report findings e.g. “Lachman’s test is negative.”

11. Medial and Collateral Ligament Strain Tests Commence at: 9:30 (60s duration)
− Tuck ankle between your right arm and right lateral thorax.
− Cradle proximal tibia (distal to joint line) with both hands and keep knee at 30
degrees of flexion.
− Test both knees, one at a time.

Medial Collateral Ligament Strain:

− Valgus strain the knee joint (bending the lower leg away from midline).

Lateral Collateral Ligament Strain:

− Varus strain the knee joint (bending the lower leg towards midline).

− Ask patient if they have any pain and note any laxity in either direction of strain.
− Report findings e.g. “The collateral ligament strain tests are negative.”

12. McMurray’s Test Commence at 10:30 (60s duration)

To start both tests:
− Fully flex knee, drawing heel close to body, with foot on bed.
− Right Hand should grip plantar surface of calcaneus, Left Hand grips anterior
surface of knee, feeling medial or lateral joint line, depending on meniscus
being tested.
− Ask patient to report any pain.

Medial Meniscus Testing:

− Externally rotate tibia by turning the foot outward.
− Slowly, fully extend the knee (straighten the leg), noting any “pop” or “click”
under the finger on the medial joint line, or signs of pain.

Lateral Meniscus Testing:

− Internally rotate tibia by turning the foot inwards.
− Slowly, fully extend the knee (straighten the leg), noting any “pop” or “click”
under the finger on the lateral joint line, or signs of pain.

− Compare both knees.

− Report findings e.g. “McMurray’s test is negative.”

− Conclude the examination and thank the patient, indicating they can redress.

4
Professional Behaviour (Essential to PASS)
− Confident approach to task
− Patient and assessor treated with respect
− Provides clear instructions to patient and clear reports to assessor
− Neatly dressed