a comprehensive and examination oriented presentation of clinical examination of knee joint.contains lot of demonstrations and tips.author is dr mohamed ashraf,professor and head of orthopaedics,govt TD medical college hospital,alleppey,kerala,india. drashraf369@gmail.com

1. KNEE-CLINICAL
EXAMINATION
DR MOHAMED ASHRAF
DORTH,MS,DNB,MNAMS
PROFESSOR AND HEAD
GOVT MEDICAL COLLEGE
ALLEPPEY,KERALA,INDIA ,
dr
drashraf36
drashraf369@gmail.com

2. Totally incongruent joint
Hence intra/extra stabilisers and load distributors
PFJ- SADDLE JOINT
TFJ-HINGE JOINT
Standing from chair-110 deg
Walking-70 deg
Running
Climbing
jumping
KNEE –SPECIAL ANATOMY

3. Components of the assessment include
Focused history
Attentive physical examination to locate pathology
Special tests or manouvers to confirm the lesion
KNEE EXAMINATION-
AN OUTLINE

4. In standing
In walking
In sitting
In supine
In profile
In prone
ADEQUATE EXPOSURE
COMPARE BOTH KNEE
KNEE EXAMINATION-HOW?

5. three sets of series are used
1. for patello-femoral/extensor mechanism pathologies;
2. for meniscal and chondral (articular) lesions;
3. For ligament instability evaluation.
Muscles
Collaterals
Cruciates
Capsule and corners
synovium
Meniscus
bones
CLINICAL ASSESMENT
PATTERN

6. KNEE-COMMON SYMPTOMS
• PAIN
• SWELLING
• LIMP
• STIFFNESS
• LOCKING
• DEFORMITIES

7.  Noncontact injury with “pop”--- ACL tear
 Contact injury with “pop”---MCL or LCL tear,
meniscus tear, fracture
 Acute swelling-ACL tear, PCL tear, fracture, knee
dislocation, patellar dislocation,capsule
 Lateral blow to the knee[VALGUS]- MCL tear
 Medial blow to the knee[VARUS]-LCL tear
 Knee “gave out” or “buckled”- ACL tear, patellar
dislocation
 Fall onto a flexed knee-PCL tear
foot fixed ,flexed or free

8. KNEE “SOUNDS”
Crepitus-oa,pfs,#s
Snapping-ITB,biceps tendon,pes
Thud-discoid meniscus
Clunk,click-meniscus,loose body

9. Pseudo locking-post capsular contracture,post structure
contusion,hamstring spasm,fat pad
fixed angle locking-longitudinal meniscus tears,acl stump
Variable angle locking-loose bodies
Subtle locking-normal 10deg hyperextension
[so even upto neutral may be locking,hence compare]
Elastic extension locking-anterior horn
Solid extension locking-arthritic
LOCKING

10.  Trendelenberg
 Antalgic
 Short limbed
 Stiff knee
 Flexed knee

12.  Jointline-medial ,lateral[arthritis,meniscus ]
 Condyles-tibial ,femoral.
 PFJ -retinacula,patella.
 Ligaments-MCL[pellegrini-steida],LCL,ACL
tibial insertion
 Q-tendinitis,sinding larson,osgood

13.  Shape,
 wasting
 power
 contracture
 Extensor lag

14.  Disuse
 Reflex inhibition
 Toxic myopathy
 Neuropathy,nerve lesions
 myopathy
 Quadriceps atrophy-usually seen in
Long-standing problem
 Vastus medialis atrophy-common
observation After surgery and injury

15.  At birth-15 deg varus,5 deg tibial intorsion,hip ER
contracture
 At 1 year-this becomes maximum
 At 2 years-becomes neutral,tibia neutral
 At 4 years- straight knee[genu rectus],tibial torsion zero
 At 8 years-adult 7 deg valgus,tibia 20 deg ER,AV15,intoeing
corrected, Physiological valgus-15 deg,IMD 8cm

16.  Increased IR&limited ER in extension
 Assesed by craig –ryder method
 Assesed by FPA [foot progression angle]
 Angle between cervical long axis and
transcondylar axis

17. Angle between transcondylar and
transmalleolar axis
Assess - by thigh foot angle[n=10][if
foot is normal]
Assess – by angle of transmalleolar
axis[angle between thigh axis and
parpendicular to trans malleolar axis]
Assess – by foot progression angle

18. Foot torsion
 Heel bisector line[middle of heel] passes
thru 2nd toe.
 V-finger test-in new born ,heel between
index and middle,normally lateral border
straight and touches finger

19.  Plumb line- from ASIS thru middle of
patella just touches medial malleolus
 Mechanical axis angle- angle between
femur and tibia-3degree varus
 Anatomical axis angle-7 degree valgus
 MAD-lower limb mechanical axis pass
8mm medial to the middle of
knee[fujisawa point]

20. Deformed knee
 Frame knee- premature epiphyseal closure
 Tripple deformity- in destructive arthritis
 quadruple deformity-tripple plus VALGUS
 Varus,valgus,procurvatum,recurvatum
 Windswept- varus and valgus
 Bizarre- charcots
 Broadened- hemophilia
 Miserable malalignment syndrome

21.  Physiological or pathological
 Pathological-
unilateral,asymmetrical,painful or
progressive
 Valgus,varus,procurvatum,recurvatum
 Cover up test-cover distal 2/3of tibia –if
varus, knee abnormality.if neutral, tibial
pathology
 Knee flexion test-tibial or femoral[except
dysplasia]

22.  Apparent bow legs-disappears on IR of
hip[AV]
 Apparent genu valgum-disappears on ER[AV]
 Normally heel touches ischial tuberosity
 Genu valgum/genu varum complex
 Asses-by IMD/ICDmeasurement,plumbline

23.  Rectus- ELY’S PRONETEST.
 V.lateralis-habitual dislocation.
 V.Intermedius-genu recurvatum.
 ITB-OBER’S test ,NOBLE compression test.
 Hamstring- tripod sign,popliteal angle
 gastrocnemius -silfverskiold
 Malunions and nonunions

24. Articular
Extra articular
Para articular

25. Articular swellings
1.Fluid swelling-
effusion,blood,.pus
2.Soft solid swelling-
synovium
3.Bony hard solid-
fixed [osteophytes, tumours]
mobile[Loose body]

26. FLUID -TESTS
• Minimal –fluid displacement test
• Moderate-patellar tap
• Severe –cross fluctuation in both planes

27. Pre patellar bursa
Infra patellar bursae
Meniscus cyst
SMB
Bakers cyst
Ganglion
Popliteal cold abcess

28.  Soft Doughy
 Pseudofluctuation-only in one plain
 Palpable,rolled but cant be displaced
 Negetive transillumination

29. PLICA LESIONS
PLICA stutter-flex knee,patella jumps during 45-
60 degrees
Mital hayden test-pain on attempted medial
movement of patella at 30 degree flexion
Hughston plica test-hip-knee90/90,IR tibia,push
patella medially,extend knee-popping of plica band
over medial femoral condyle

30.  Sitting knee 90,standing
 Thickening-old injury,infection
 Bipartite-superolateral swelling
 Prominent- Q wasting
 Squint patella- AV more[frog eye]
 High patella ,low patella

31.  Normal-linear during extension
 Abnormal-inverted J[J SIGN] more in ER
 Dynamic tracking-90 to full extension
 Active tracking-in extension Q contracted-
moves up normally-sideways abnormal

32. Zohlens test-resist against quadriceps
Friction test-press down
Push test-for facet tenderness
Sage sign- > 1cm mediolateral mobility
Patellar retinaculum,MPFL- glide test,
apprehension test
Critical angle-at which patella dislocates[less-
bad]
Abnormal vertical mobility

33. check
 active
 Passive
 Abnormal
 Provocative
during movement look for
1.Range 2.Arc 3.painful 4.muscle spasm 5.sounds
6.stability

34.  Circumferential- at 0,5,15 cm
 Linear-plumb,axis .
 Angular-sagittal,coronal,Qangle,tuber
sulcus angle
 Limb length-apparent,true,segmental
 Torision -Craig/ryder , tibial torision
 IMD,ICD
 Thigh-leg angle,thigh-foot
angle,transmalleolar axis

35.  Brattstrom-angle of instability
 Supine-male-100, female- 150
 Standing-20 flexion-male140 ,female 170
 tubercle sulcus angle-in sitting /patella centre to
tubercle centre/ vertical drop from
centre-angle -male-50,female-80

36. MENISCUS LESION
-WHICH AND WHERE?
• Flexion rotation-post horn
• Midflexion rotation-body
• Extension rotation-ant horn
• Valgus stress-lat meniscus
• Varus stress-med meniscus
• Post traumatic pain and jointline tenderness
• Springy lock,clicks,recurrent effusion
• Q wasting

37. MENISCUS
-COMPRESSION/ROTATION
TENDERNESS
• Apley's (grinding) test is carried out with the patient prone and the
knee flexed to 90°. Then the leg is twisted and pulled, then pushed. If pain is
felt only while pushing, a meniscal lesion is diagnosed
• Bohler's test a varus stress and a valgus stress are applied to the knee:
pain is elicited by compression of the meniscal tear.
• Squat test, duck walking test [childress test]- consist in several
repetitions of full weightbearing flexions on the knee, in IR and ER
• Bounce home test-painful passive extension after full active flexion

38.  Merke's test - patient in a weightbearing position:
body internally rotates and tibia rotates externally
pain if medial meniscus is torn.
The opposite occurs when lateral meniscus is torn.
 Peyr's test - sit inTurkish position[ fig of 4]
thus stressing the medial joint line:
pain is positive for a medial meniscal lesion.
 Steinmann's knee flexed at 90°
forced to external rotation,
then internal rotation:
medial meniscal tear if pain upon externally rotating,
lateral meniscal tears if pain during internal rotation.
Steinmann 2- tenderness point moves anteriorly in extension
and posterioly in flexion

39. MCMURRAY-OLD STILL GOLD
• Full flexion ER [abd] extension-med
• IR [add]-lat
• Click sound significant than pain
• Negetive test-don’t rule out meniscus tear

40. Thessaly test
 Examiner support the hand of the patient
 Normal knee in 5 and 20 degree flexion
and thrice rotations[IR,ER]
 Click and pain in 20-more diagnostic
 Most sensitive-joint line tenderness

41.  ACL approximated against medial femoral
condyle-pain
 Internal rotation of fully flexed tibia and
extension-cause pain at 30 deg relieved by
external rotation
 Axhausen sign-direct tenderness over
lesion[active or healing]

42. KNEE LAYERS
• Layer 1-marshalls arciform layer anteriorly,sartorius
medially,biceps laterally
• Layer 2-LCL,PATELLAR TENDON,superficial MCL
• Layer 3-post oblique lig,arcuate lig,deep MCL
• [Intra-articular extra synovial-ACL,PCL]

43. LIGAMENTS
• Stabilise the knee in one or more plains
• Help in mobility in a controlled fashion
INJURY LEADS TO
• 1.uniplanar or rotatory instability
• 2.stiffness due to adhesions
• 3.pain due to focal or local chondral injury
• 4.pain due to secondary arthritis

44. LIGAMENT- INJURY MECHANISM
• 1. knee abduction,flexion ER [femur IR]-medial and
posteromedial structures torn
• 2.knee adduction,flexion IR[femur ER]-lateral and
posterolateral structures torn
• 3.hyperextension-ACL Post capsule PCL
• 4.sagittal displacements-ACL or PCL
• 5.isolated injury rare .rarely ACL may be [other associated
injuries might be healed]

45. Tenderness-attachments,midsubstance
Gap
Hemarthrosis-may be absent in severe case
Stability-asses normal side,preferably under
anesthesia
Often multi ligament-precise diagnosis?
Arthrometer-to measure sagittal and coronal
translations
LIGAMENT INJURY-
CLINICAL ASSESMENT

46. Localise-which ligament
Classify-single or MLKi
Grade – 1,2,3 [1+,2+,3+]
Depends on –position of knee during injury
amount of force,
direction of force,
post injury knee position,stability,
patients description,
timing and location of knee swelling

47.  Single plain-
medial,lateral,anterior,posterior
 Rotatory-AM,AL[in flexion or towards
extension],PL,PM
 Combined instability-
AL/AM,AL/PL,AM/PM

48. INSTABILITY- LIGAMENTS INJURED
• Medial extension-MCL,capsule,oblique popliteal
lig,ACL
• Medial in 30 flexion-Above + ACL
• Lateral in extension-LCL,Arcuate,popliteo fibular
lig,biceps,ITB,ACL, PCL probably
• Lateral in 30 flexion-lateral lig complex
• Posterior-PCL / PCL + PLC
• Anterior-ACL / ACL +

49. STABILITY TEST TO ASSES….
• MEDIAL COLLATERAL
• LATERAL COLLATERAL
• ANT CRUCIATE
• POST CRUCIATE
• PLC,PMC
• EXTENSOR MECHANISM
TESTS 1.STRESS TEST
2.SLIDE TEST
3.PIVOT TEST
4.ROTATORY TEST

50.  Isolated
 Along with meniscus
 Unhappy triad o’Donoghue
 Chronic attrition rupture in OA,RA

51.  90 degree flexion,sit close to foot
 THUMB ONTIBIALTUBERCLE,FINGERS ON HAM
 In 15 deg external[AMI] and 30deg int rotation[ALI]
 FALSE POSITIVE AD[PCL]
 FALSE NEGETIVE-tense hemarthrosis,door stopper
menisci,hamstring spasm
 Grading-5mm-1,5-10 -11,>10-111
 WEATHERWAX modification-leg in examiners axilla[anterior
translation better appreciated]
 NOYES modification-thumb on LCL,MCL to detect varus,valgus
instability
 FEAGIN modification-patient in sitting position to reduce ham
spasm
 ACTIVE DRAWERTEST-knee 90,foot fixed,ask patient to
straighten knee,tibia moves forward

52.  90 + IR- test ITB ,ACL,PCL,PLC
 90+NEUTRAL-
ACL,COLLATERALS,sometimes PCL
 90+ER-ACL,PMC
 6-8mm translation-positive
 Note tibial condyle rotation
 Assure initial neutral position of tibia

53.  Convenient position
 MORE SENSITIVE
 Less painful
 Not affected by meniscus,blood,torn
collaterals.
 End points in stress test-
 hard-normal ligament
 firm-partial or elongated
 soft-complete rupture

54.  PRONE lachman -obesity
 CLASSICAL lachman-passive
 ACTIVE lachman-patient extends knee
 TRILLAT MOD-thumb on tibial tuberosity
 SITTING lachman-knee flexed in your lap

55.  Normally 1cm ant stepoff tibial condyle
from femur
 If this is absent-may be post drawer
positive
 Most sensitive for PCL
 Post drawer >10 mm-PCL and PLC

56.  Post sag test[gravity drawer test] –in 90-90
 If pushed further goes-godfreys test
 Reverse lachman test

57.  Anterior drawer position
 In PCL injury-tibia translates post
 Ask patient to contract Q-tibia moves 2mm
forward

58.  Valgus in 30
 Valgus in 0-combined
 Slocum modified ant drawer-combined
 Ant drawer test in ER- combined

59. Oo instability- LCL and
PLC/ACL/PCL
200-300 instability- LCL

60.  Antero-medial-medial tibial condyle
rotates externally along with ant
translation
 Ant drawer and valgus stress positive
 Antero lateral-just opposite
 Postero lateral rotatory-lcl ,pcl,plc

61.  Pivot –gerdys tubercle
 Axis-intact PCL
 Most sensitive under anesthesia-bach b r jr

62. 1.Recurvatum ER test
Extension instability
 Knee goes for recurvatum and ER
2.Dial test[tibial ER test]
 At 30 deg-PLC
 At 30 and 90 deg-PLC +PCL

63.  Patient supine-hip 45,knee 85,tibia 15 ER
 Do post drawer
 Lat tibial condyle-ER + in PL
instability/+++PLC ,PCL
FIG OF 4TEST
 Knee in fig of 4 position
 Press knee down
 Pain over PL corner

64. No knee examination is complete without
popliteal fossa examination for
 1.hard swellings eg osteochondroma
 2.firm swelling eg neurofibroma
 3.soft swelling eg lipoma
 4.cystic swelling eg bakers cyst.SMB,cold
abcess
 5.pulsatile swelling- popliteal aneurysm


65.  Hip,ankle,spine,opp limb
 NVD
 Node
 Poplitaeal true /pseudo aneurysm
 Lat popliteal injury-10-3-5 IN PLC
 BAKER CL,DeLee jc,laprade RF

66. THANK YOU

67. DR MOHAMED ASHRAF
MBBS [GMC CALICUT]
DORTHO[GMC TRIVANDRUM]
MS ORTHO [ MMC MADRAS]
DNB [ NEW DELHI]
drashraf369@gmail.com