Knee Examination PDF
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Fairleigh Dickinson University
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Summary
This document provides an overview of knee examination procedures, including inspection, palpation, and specific tests. It details bony landmarks, soft tissues, and joint lines, as well as provocative tests for ligament injuries like ACL and PCL. The content is intended for medical professionals.
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The Knee ○ The knee joint is the largest joint in the body ○ It is a hinge joint involving 3 bones: the femur, the tibia, and the patella (or knee cap) ○ There are 3 articular surfaces, 2 between the femur and the tibia and one between the femur and the patella Note how the...
The Knee ○ The knee joint is the largest joint in the body ○ It is a hinge joint involving 3 bones: the femur, the tibia, and the patella (or knee cap) ○ There are 3 articular surfaces, 2 between the femur and the tibia and one between the femur and the patella Note how the 2 rounded condyles of the femur rest on the relatively flare tibial plateau ○ Inspection Skin Discoloration, wounds, gross deformity, or previous scars Soft tissues Swelling, muscle atrophy, symmetry Bony Length- compare to contralateral side Position – genu varum or valgus; flexion contractures Gross deformity or malalignments GAit Varus thrust ○ Can indicate LCL or PLC insufficiency or injury Antalgic (painful) ○ Shortened stance phase on affected side Patella tracking Flexed knee gait ○ From tight achilles tendon or hamstrings ○ Palpation Bony Joint line ○ Tenderness to palpation medially or laterally Patella ○ Translation ○ Facet pain to palpation Tibial tubercle Soft tissue structured Pes anserine bursa Patellar tendon Quadriceps tendon Iliotibial band Collateral ligaments Popliteal fossa Pain with Baker’s cyst or popliteal cyst ○ Learn bony landmarks in and around the knee These will guide your exam of this ○ complicated joint Medial surface: identify the adductor tubercle, the medial epicondyle of the femur, and the medial epicondyle of the tibia, pes anserine Anterior surface: identify the patella, which rests on the anterior articulating surface of the femur midway between the epicondyles, embedded in the tendon of the quadriceps muscle. This tendon continues below the knee joint as the patellar tendon, which inserts distally on the tibial tuberosity Lateral surface: find the lateral epicondyle of the femur, the lateral condyle of the tibia, and the head of the fibula ○ Powerful muscle groups move and support the knee. It is important to remember that both of these muscle groups also have components that cross the hip joint and so act to flex and extend the hip as mentioned in the last section Quadriceps femoris is made up of 4 muscle bellies that extend the knee and cover the anterior, medial and lateral aspects of the thigh Hamstring muscles lie on the posterior aspect of the thigh and flex the knee Medial and lateral menisci: cushions the action of the femur on the tibia. These crescent shaped fibrocartilaginous discs add a cuplike surface to the relatively flat tibial plateau. They are often difficult to specifically palpate Medial collateral ligament (MCL), not easily palpable because of its broad and flat shape, is a ligament connecting the medial femoral epicondyle to the medial condyle of the tibia. The medial portion of the MCL also attache to the medial meniscus Lateral collateral ligament (LCL) connects the lateral femoral epicondyle the head of the fibula. The MCL and LCL provide medial and lateral stability to the knee joint Anterior cruciate ligament (ACL) crosses obliquely from the anterior medial tibia to the lateral femoral condyle, preventing the tibia from sliding forwards on the femur Posterior cruciate ligament (PCL) crosses from the posterior tibia and lateral meniscus to the medial femoral condyle, preventing the tibia from slipping backward on the femur ○ ROM Flexion 125-135 deg Extension 0-10 deg hyperextension Rotation (stabilize femur) 10-15 deg internal and external tibial rotation Meniscal injury ○ McMurray Test: With the patient supine, grasp the heel and flex the knee Cup your other hand over the knee joint with fingers and thumb along the medial joint line From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, slowly extend the lower leg in external rotation The same maneuver with internal rotation of the foot stresses the lateral meniscus If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a tear ACL ○ Provocative tests Lachman’s test Most sensitive exam test Place the knee in 15* of flexion and milk external rotation Grasp the distal femur on the lateral side with one hand and the proximal tibia on the medial side with the other With the thumb of the tibial hand on the joint line, forcefully and simultaneously pull the tibia forward and the february back. Estimate the degree of forward excursion. There should be a firm endpoint to any forward movement. Lack of a firm excessive movement may indicate the ACL is no longer intact Anterior drawer Patient supine w/knee flexed to 90 degrees Examiner stabilizes the foot by sitting on it. Fingers in popliteal fossa with thumbs on lateral and medial joint line. Gently, pull the tibia forward. Positive test if tibia displaces forward (anterior) PCL ○ Provocative tests Posterior drawer sign: Position the patient and place your hands in the position described for the anterior drawer test S it on the patient’s foot to minimize foot movement Push the tibia posteriorly and observe the degree of backward movement in the femur. There should be minimal posterior movement and excursion of the tibia relative to the femur. Excessive movement suggests an insufficient or torn PCL MCL ○ Provocative tests Abduction (or Valgus) stress test With the patient supine and the knee slightly flexed, move the thigh about 30* laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress). Feel for excessive widening of the joint and lack of endpoint that may signal the ligament is no longer intact LCL ○ Provocative tests Adduction (or varus) stress test With the thigh and knee in the same position, change your position so that you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and pull medially at the ankle to open the knee joint on the lateral side (varus stress). Feel for excessive widening of the joint and lack of endpoint that may signal the ligament is no longer intact Special Techniques: tests for knee joint effusions ○ Bulge sign (for minor effusions) With the knee extended, place the left hand above the knee and apply pressure on the suprapatellar recess ro displace or “milk” fluid downward. Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area. Tap the knee just behind the lateral margin of the patella with the right hand ○ Balloon test (for major effusions) Place the thumb and index finger of your right hand on each side of the patella; with the left hand, compress the suprapatellar recess against the femur Palpate for fluid ejected or “ballooning” into the spaces next to the patella under your right thumb and index finger ○ Neurovascular Motor Knee flexion– sciatic nerve Knee extension – femoral nerve Foot plantarflexion – tibial nerve Foot dorsiflexion – deep peroneal nerve Sensory Medial thigh – obturator nerve Anterior thigh –femoral nerve Posterolateral leg – sciatic nerve Dorsal foot – peroneal nerve Plantar foot – tibial nerve Pulses Popliteal Dorsalis pedis Posterior tibial Reflexes Patellar (L4) ○ hypoactive/ absent is concerning for L4 radiculopathy ○ Hyperactive may indicate UMN injury
