22 - Examination of the knee

Summary

Checklist

WIPER

• Patient standing in shorts or underwear; hip and ankle joints exposed.

Physiological parameters

Gait

• Asymmetry of spine and pelvis

• Antalgic gait and walking aids

• Soles of footwear

Tape

• Quadriceps diameter: muscle bulk

Look

• Skin: scars, erythema, ecchymoses, sinuses, skin creases

• Soft tissues: wasting of quadriceps, swelling in popliteal fossa, knee effusion

• Bone:

• deformity or asymmetry

• pelvic tilt

• posterior subluxation of the tibia on the femur

• varus/valgus deformities of the knee

• flexion deformity or recurvatum

Feel

• Skin: temperature, tenderness

• Soft tissues:

• knee effusion and ‘ bulge ’ test

• patellar tap test

• popliteal fossa: Baker's cyst, popliteal artery aneurysm

• tendons: quadriceps tendon, patella tendon, pes anserinus, collateral ligaments and menisci, iliotibial band

• pulses, capillary refill, neurology

• Bone:

• tibial tuberosity and patella

• femur, tibia and joint line

• origin and insertion of collateral ligaments

Move

• Active:

• straight leg raise

• flexion and assess for crepitus

• extension against gravity

• Passive

• flexion

• hyperextension

• Resisted

• flexion

Special tests (* = essential tests)

• Patella: patella apprehension test,* patella tracking test, Clarke's test

• Collateral ligaments: valgus/varus pressure* (knee flexed at 30° flexion and extension)

• Menisci: McMurray's test*

• Cruciate ligaments: posterior sag test,* anterior & posterior drawer test,* Lachman's test,* pivot shift test, dial test

To complete the examination…

• Examine the joint above (hip joint) and the joint below (ankle joint).

• Check full neurovascular status of the lower limb.

• Order appropriate radiographs and further imaging.

Examination notes

How do you measure quadriceps diameter in order to assess wasting?

• Locate the tibial tuberosity. This is found on the proximal anterior tibia and demarcates the insertion of the patella tendon.

• Mark a point 20 cm proximal to this landmark, which is mid-thigh. (A longer measurement may be required in very tall individuals.)