Knee examination

1. Presenter : Dr.Subodh Pathak

2.  The knee is a Hinge type synovial
joint, which is composed of three
functional compartments:
 Femoropatellar
 Medial femorotibial articulation
 Lateral femorotibial articulation

3.  KNEE IS A COMPLEX JOINT:
1.HINGE TYPE: flexion extension of
about 0-140 degree possible.
2.PIVOT TYPE: provides rotational
movement of about 5-25degree.

5.  Femur: Lateral and Medial condyle
 Tibia: Tibial condyles are
separated by the intercondylar
eminence
 Patella

6. On the medial side, the femur meets the tibia
like a wheel on a flat surface, whereas on the
lateral side, it is like a wheel on a dome.

7.  Lateral condyle lies more
directly in line with the
shaft,slightly anterior ,
and is Smaller.
 Medial condyle is in line
with the femoral head,
slightly posterior and is
Larger, extending further
distally.
 Hence the distal femur
remains essentially
horizontal.

8. Is asymmetrical
Medial tibial plateau:
Longer in AP direction.
Lateral tibial plateau is
smaller in AP direction but
has a larger articular
cartilage.
Tibial plateau slopes
posteriorly approx. 7 to
100.

9.  Inverted triangle with apex
pointing inferiorly.
 Posterior articulating surface
has a vertical ridge dividing it
equally into medial and lateral
facets.
 2nd medial vertical ridge that
forms the odd facet.
 Functions primarily as the
pulley to the quadriceps.
 Femoral sulcus on the anterior
aspect of distal femur. Has a
central groove that
corresponds to vertical ridge of
patella.

10. ACTION ( flexion / extension ) RANGE IN DEGREES
Normal range 130 – 140
Squatting Upto 160
Normal gait 60-70
Ascending stairs 80
Sitting down / rising from a chair 90

13. Intracapsular Ligaments
ACL
PCL
Transverse ligament
Anterior meniscofemoral ligament
Posterior Meniscofemoral Ligament
Meniscotibial ligaments

14. Extracapsular Ligaments
 Patellar ligament
 Medial collateral Ligament
 Lateral Collateral ligament
 Oblique popliteal Ligament
 Transverse popliteal Ligament

16.  Arises in front of intercondylar eminence of
tibia
 Inserts into semicircular area on the
posteromedial aspect of lateral femoral
condyle.
 33mm long , 11 mm broad.
 It twists about 90 from tibial to femoral
insertion.
2 Bundles:
 Anteromedial (tense with flexion)
Posterolateral (tense in extension)

17. M L
Function
Resists anterior tibial
translation
Prevent hyper
extension
Secondary restrain to
both valgus and varus

18.  ACL is taut between – full extension and 20 degree( lachmans test)
 Relax between 30-40 degree ( max at 40)
 Tension of ACL raises again at 70 to 90 degree( anterior drawer
test)

19.  Arises from posterior margin of
tibia inferior to tibial articular
surface inserted into lateral wall
of medial epicondyle of femur.
 Two bundles :
 Anterolateral (tense with flexion)
Posteromedial (tense in
extension)
*
PCL is more vertically oriented,
and is the axis around which
rotation of knee occurs.

20.  Serves as the primary restraint to posterior
translation
 Restrains force better at flexion.maximally at
75 to 900 flexion.
 Also restrains varus and valgus stresses.
Extension Flextion

23.  Menisci are crescentic laminae deepening the
articulation of the tibial surfaces that receive
the femur. Their peripheral attached borders
are thick and convex, their free borders thin
and concave.
 Peripheral zone is vascularized by capillary
loops from the fibrous capsule and synovial
membrane
 Inner regions are avascular

25. MEDIAL MENISCILATERAL MENISCI
 C- shaped
 Larger exposed surface
hence greater
susceptibility to
compressive loads.
 Genu varum increases
force
 Greater ligamentous and
capsular restraints(deep
portion of the MCL) ,
limiting translation(more
susceptible to injury)
 Semimembranosus muscle
is attached.
 4/5th of a circle
 Covers a greater % of area
 More medially, part of the
tendon of popliteus is
attached to the lateral
meniscus, and so mobility
of its posterior horn may
be controlled by the
meniscofemoral ligaments
and popliteus

26. Importance:
1. Improves the
congruence
2. Distribution of
weight bearing
forces
3. Reducing friction
4. Serving as shock
absorbers
5. Prevents capsular
and synovial
impingement.

27. ANTERIOR LATERAL MEDIAL
Suprapatellar Lateral gastrocnemius
[subtendinous] bursa)
Medial gastrocnemius
[subtendinous] bursa
prepatellar fibular (LCL-biceps) Anserine(MCL-Anserine)
Deep infrapatellar Fibulopopliteal(LCL-pop) Bursa semimembranosa
(MCL-Semimem)
Superficial infrapatellar Subpopliteal(pop –lat
Condyle of femur)
Between
semimembranosus
tendon and head of
tibia.
Pretibial(tibial
tuberosity-Skin)
Between
semimembranosus and
semitendinosus.

28.  When???
 How???
 Symptoms??
 Level of Activity??

29. ◦ Position of the knee in respect to body as a whole
at the time of injury

30. 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
Lateral blow to the knee MCL tear
Medial blow to the knee LCL tear
Knee “gave out” or “buckled” ACL tear, patellar dislocation
Fall onto a flexed knee PCL tear

32.  Character?
 Severity?
 Exact site of pain?
 Time?
 Pain at night -Inflammatory cause--
mechanical in origin.
 Pain when going up or down stairs, or
aching in positions where the knee is kept
flexed for prolonged periods of time (car
journeys, visits to the cinema), ---Patellar
problems,

33.  Pain when going up or down stairs, or
aching in positions where the knee is kept
flexed for prolonged periods of time (car
journeys, visits to the cinema) ---Patellar
problems
 Pain that occurs when the knee is
hyperflexed (meniscal pathology)

34.  Onset of Pain
◦ Date of injury or when symptoms started
 Location of pain*
◦ Anterior
◦ Medial
◦ Lateral
◦ Posterior

35. • Anterior – Patellofemoral syndrome, bursitis,
Osgood-Schlatter’s disease, patellar tendinitis,
patellar fracture
• Medial – meniscus, MCL, OA, pes anserine
bursitis
• Lateral – Meniscus, LCL, OA, iliotibial band
friction syndrome, fibular head dysfunction
• Posterior – hamstring injury, tear of posterior
horn of medial or lateral meniscus, Baker’s cyst,
neurovascular injury (popliteal artery or nerve)

37. Look
Feel
Move

38. Notes on Ottawa Knee Rules
1. Age 55 or older
2. Point tenderness at patella (no bone tenderness of knee other than patella)
3. Tenderness at head of fibula.
4. Knee cannot be flexed to 90 degrees
5. Patient unable to bear weight for four steps immediately and in the emergency
department or office.
Tips for Accurate Usage:
Tenderness of patella only counts if it is the only area of the bone tenderness in the knee
Inability to bear weight means patient is unable to transfer weight twice onto each leg regardless of
limping
Sensitivity - 100%
Negative predictive value 100%
Specificity 49%
Compared with examination, MRI more sensitive for ligamentous and meniscal damage but less specific.

39.  Expose both lower limbs
 Postions
◦ Standing
◦ Seated position
◦ Supine position
◦ Prone position

40.  Anteriorly
 Laterally
 Medially
 Muscle wasting
 Popliteal fossa
 Alignment

41.  Always indicative of a genuine lesion of
the joint
◦ Causes
 Infective
 Traumatic - effusion – hemarthrosis,
dislocated patella, knee dislocation ,
fracture
 Degenerative
 Bursitis
 Tumors
 Popliteal aneurysm

42.  Surface Anatomy (Ant )
Hollow
PATELLA
•Appears hollow on either side of patella
•There is a slight indentation above the patella
•A small amount of fluid will make these hollow-appearing areas
disappear. Larger effusions are most conspicuous as a fullness
proximal to the patella.

43. 43
Patella:
Lateral and Medial Patellar Facets
Superior
And
Inferior
Patellar Facets
Patellar Tendon**
Lateral Fat Pad
Medial Fat
Pat

44.  Patella is Normally oval
 Presence of
BIPARTITE PATELLA ,
distortion of this shape
may be visible.
 Manifested as
Protruding
prominence
at the supralateral
aspect of patella

45.  The infrapatellar fat pad, also known
as Hoffa's fat pad, is a cylindrical piece
of fat that is situated under and behind
the patella.

46.  Patellar Tendon inserts on bony prominence
called Tibial Tubercle
 Prominece enlarged in Osgood–Schlatter
disease

47. 47
Medial
Femoral
Condyle
Patella
Joint
Line
Medial
Tibial
Condyle
Tibial
Tuberosity

48. 48
Medial Collateral Ligament (MCL)*
Pes anserine
bursa**
Medial joint
line

49. 49
Lateral joint
line
Lateral Collateral
Ligament (LCL)**

50.  Chronic Lateral meniscal tear---a localised
band of synovitis may occur along lateral
joint line creating a charactersitic buldge.

52.  Medially—
Semimembranous(A) &
Semitendinious(B)
 Laterally—Biceps
Femoris(C)
 D=Common peroneal
Nerve
 E=Medial head of
Gastrocnemius
 F=Lateral Head

53.  Look in the thigh
 Quadriceps wasting
 Vastus medialis
wasting
 Very often seen after
an old injury to the
meniscus.

54. Anterior
 Prepatellar Bursitis
 Infrapatellar Bursitis
 Suprapatellar bursitis
Medially
 Pes anserine bursitis
Posteriorly
 Morrant Bakers cyst
 Popliteal Aneurysm
 Semimembranous Bursitis

55.  Housemaid's knee
 Egg like swelling Anterior to Patella
 Nodule Formation can be seen or palpated in
prepatellar bursa in chronic inflammation

56.  Clergyman's knee

57.  Occurrence of pes anserine bursitis
commonly is characterized by pain, especially
when climbing stairs, tenderness, and local
swelling.

58.  A Baker's cyst, also known as a popliteal cyst,
is a benign swelling of the semimembranous
or more rarely some other synovial
bursa found behind the knee joint
 Best Seen in patient prone and relaxed

59.  Superficial palpation:
 Temperature
 Skin Surface
 Elasticity of skin
 Check for Swelling or Sinus

60.  A mark on the knee is made 10-15cms above the
suprapatellar margin.
 Compare with Normal.

61.  Doughy or Earthworms filled in bag
 Usually its Warm
 The edge of synovial swelling can be
palpated and rolled under the fingers
 Swelling cannot be Squeezed out to another
compartment of the knee jt.
 Trans illumination is Negative

62. With the left hand to squeeze any fluid from
the pouch into the joint. With the other hand
the patella is then tapped sharply backwards
onto the femoral condyles. In a positive test the
patella can be felt striking the femur and
bouncing off again.

63. Patient in Supine position
Knee in 10 degree Flextion
 Done when very little fluid
in the joint
 With the help of palm milk
the potential effusion from
medial side to Lateral Side
or suprapatellar region.
 Reverse manoeuvre on
lateral side.
 If rapid filling occurs
Buldge test is positive.

64.  Normally Physiologic
Valgus Alignment of
about 7 degree in
Females and 5 degree
in males

66.  Post Polio paralysis

67.  Simple screening method
 Supine postion, passive, 10cm from couch
 patient's feet are braced against the examiner's
abdomen,
 may seek to reduce the flexion deformity by
pressing down on the patient's knees
 In Prone
◦ Firm table
◦ Edge
◦ Distance between two heels
◦ In cms
◦ 1cm = 1 degrees

68.  Position
 Palpating the
borders
 Tenderness
 Mobility
 Tracking
 Q angle
 Tests
◦ Apprehension
◦ Grind test

69.  Net effect of pull of
quadriceps and the
patellar tendon is clinically
assessed by the Q angle.
 It helps predict the
tendency of patella to
subluxate.
 Normal 10 – 150 In full
extension.
 An increase in Q angle
leads to increase in lateral
force of patella. leading to
subluxation/ dislocation.

70.  - Q angle is increased by:
- genu valgum
- increased femoral anteversion
- external tibial torsion
- laterally positioned tibial tuberosity
- tight lateral retinaculum

71.  Tubercle-sulcus
angle
 normally
◦ <8° in women and
◦ <5° in men
Figure 6-22. Tubercle-sulcus angle.

73.  In a fully extended
knee the patella lies
on the femoral
sulcus.
In this position the patella is not in the intercondylar
groove, joint congruency is less hence instability.
 So Higher the patella higher the instability

75.  Ratio of length of patellar tendon to length
of the patella. Normally = 1/1
 Markedly long tendon (high patella)-
“PATELLA ALTA.”
 In patella alta the patella is is proximal to
the lateral lip of the femoral sulcus thus
high chances of subluxation.
 Low lying patella – “PATELLA BAJA”

76. patella alta : > 1.2 (>1.5)
patella baja : < 0.8 (<0.74)

77.  Normally in sitting position, the patella
points forwards.in patella Alta it faces
upwards.
In sitting if patient with subluxation / rotation
malalingnment extends the knee, a sudden
lateral displacement is seen called “ J sign / J
tracking ”

78.  Patellar Grind test
 Passive—Crunching Sensation transmitted through patella
 Active

80. Step up-Step Down test
 Remb: Hypertrophied Synovial folds may
produce a much Softer popping Sensation

81.  Knee at 90 deg to
full extension
 Shifts laterally at
terminal extension
 Excess lateral shift
/Lateral tilt morked
marked/tilt
terminally indicates
patellar instability
Figure 6-66. Assessing patellar tracking.

82.  Patient Supine
 Grasp the Sympt limb at
ankle and allow the knee to
be Flexed over the Side of
table.
 Push the patella as far
laterally as possible
 Then slowly flex the knee
with other hand
 Creates an APPREHENSION
that episode of instability is
imminent

84. • Patient supine
• Normal extremity should be examined initially
to gain confidence and to determine patient’s
normal ligamentous tightness
• Flex knee approximately 30 degrees
• Place one hand on lateral aspect of knee and
the other supporting the ankle. Gently apply
valgus stress to knee while the hand at the
ankle externally rotates the leg slightly. Bring
the knee into full extension and repeat

85. 85
Note Direction Of Forces

86. • Alternatively, examiner can place patient’s
ankle in axilla, place one hand on each side
of the knee near the joint line, and then
gently produce a rocking motion

87. • Performed in a similar manner with varus
stress applied to knee joint
• Tested in flexion
- posterior capsule is relaxed
- cruciates are relaxed
- ligaments are stretched
• If significant varus and valgus instability is
produced - cruciate ligament disruption in
addition to collateral ligament disruption

89. 89
Note direction of forces

90.  1st degree – Joint surfaces separated 5 mm
or less. Indicates tear to minimum number
of fibers with no instability
 2nd degree – Separation 5 to 10 mm.
Indicates disruption of more fibers with
more loss of function with mild to moderate
instability
 3rd degree – Separation > 10 mm. Indicates
complete disruption with marked instability

91.  Anterior Drawer Test
• Patient supine
• Flex hip to 45 degrees and knee to 90 degrees,
placing foot on the tabletop (to relax
hamstrings)
• Sit on dorsum of patient’s foot to stabilize it,
place both hands behind the knee. Thumb on
anterior joint line
• Repeatedly pull and push the proximal part of
leg anteriorly and posteriorly
• Drawer of 6-8 mm is positive

92. • Done in 3 positions – neutral, 30 degree
external rotation and 30 degree internal
rotation
• If equal drawer is seen in neutral and
external rotation position – ACL and
posteromedial portion of joint capsule (with
MCL) tear
• If equal drawer is seen in neutral and
internal rotation position – ACL and
posterolateral portion of joint capsule (with
LCL) tear

94. Lachman’s Test
• Patient supine with knee
flexed to 10-15 degrees.
• One hand stabilizes
femur while the other
grips proximal tibia
• Thumb on anteromedial
joint margin
• Lifting force-- the tibia in
relation to the femur is
palpated by thumb
• Anterior translation of
the tibia indicates a
positive test

95. 95
 View from lateral aspect*
Note direction of forces

96.  Stabilized Lachman’s Test
• Examiner’s thigh is kept under patient’s knee
• In painful conditions

97.  Modified Lachman’s Test
• Leg is supported by the table
• If the athlete's leg is too large to hold up or
the examiners hands are too small to get a
good grip

98.  Posterior Drawer Test
• Performed in a similar manner. Posterior
force is applied to proximal tibia
• Place both knees in similar position
• Thumb on each anteromedial joint line
• Loss of the normal 1 cm anterior step-off of
medial tibial plateau with respect to the
medial femoral condyle indicates torn PCL

99.  Posterior Drawer test

100. If patient starts to raise the foot from this position, pull of quadriceps
first displaces tibia anteriorly into neutral position until anterior
cruciate ligament is tight . Only then is foot raised from table

101.  Posterior Sag Test (Godfrey’s Test)
• Both hips and knees are flexed to 90 degrees
• Heels supported by examiners hands
• Sagging of tibia posteriorly due to effect of
gravity is noted
• Lateral observation is required

102.  Quadriceps Active Test
• Patient supine, knee 90 degrees as
in drawer test
• If PCL is ruptured, the tibia sags
into posterior subluxation
• Gentle quadriceps contraction to
shift tibia without extending knee
• An anterior shift of the tibia of 2
mm or more is seen if test is
positive

103. Contraction of the quadriceps muscle in a knee
with a posterior cruciate ligament deficiency
results in an anterior shift of the tibia of 2 mm
or more.

105. Slocum Anterior Rotary
Drawer Test
• This is done as in anterior drawer with 3 positions –
neutral rotation, 15 degree internal rotation (PCL is
taut) & 30 degree external rotation
• A positive anterior drawer test in neutral tibial rotation
that is accentuated in 30 degrees of external tibial
rotation and reduced when performed in 15 degrees
of internal tibial rotation, indicates anteromedial
rotary instability
• Opposite indicates anterolateral rotary instability

107.  Pivot Shift Test of Macintosh
 ( E----F)
 "When I pivot, my knee shifts”
• Done for Anterolateral rotary instability
• Patient supine, knee extended
• Tibia is internally rotated while valgus stress is
exerted over knee
• In this position, tibia is subluxed anteriorly
• Knee is flexed to 30 degrees—Anteriorly
Subluxated tibia spontaneously reduces into its
Normal Position Resulting is sudden visible
JUMP

108. • Isolated tear of the anterior cruciate ligament
produces small subluxation. Greater
subluxation occurs due to involvement of
lateral capsular complex or semimembranosus
• Elicited while moving the knee to flexion(30)
with internal rotation and valgus
• Best place to watch the Jump is Gerdy tubercle

109.  Reverse Pivot Shift Sign of Jakob,
Hassler and Staeubli
• (F-----E)
• Done for Posterolateral rotary instability
• Patient supine, knee 90 degrees flexed
• Tibia is externally rotated while valgus stress is
exerted over flexed knee
• Causes lateral tibia to subluxate posteriorly
(seen as posterior sag) in relation to lateral
femoral condyle

110. • Knee is extended
• As the knee approaches 20* of flextion
Lateral tibial plateau moves anteriorly in a
jerk like shift from a position of posterior
subluxation and external rotation into a
position of reduction and neutral rotation
• Elicited while moving the knee to extension
with external rotation and valgus

112.  Jerk test of Hughston and Losee
• Done for anterolateral rotary instability
• Patient supine, knee 90 degree flexed
• Tibia is internally rotated while valgus
stress is exerted over knee
• Knee is extended gradually
• When positive, lateral tibia subluxates
forward in form of sudden jerk at 30
degree of flexion
• Elicited while moving the knee to
extension with internal rotation and
valgus

114. Flexion Rotation Drawer Test
 Done for Anterolateral rotary instability
• Patient supine, knee extended
• Lift the leg upward, allowing the femur to fall
back and externally rotate the leg
• Anterolateral tibial subluxation is the starting
position for this test
• Knee is flexed, the tibia moves backward and
the femur rotates internally, causing the joint
to reduce when the test is positive

116. External Rotation Recurvatum Test
• Done for posterolateral rotary instability and PCL
• Patient supine, knee is moved from 10 degree
flexion to maximal extension
• External rotation and recurvatum is noted
• If excessive with varus deformity, test is positive

117.  McMurray’s Test
• Patient supine
• To check medial meniscus, examiner stands on
affected side
• Grasps foot firmly in one hand and knee in other
hand. Knee joint is completely fixed
• Foot rotated externally and abduction stress
given at knee

118. • Joint is slowly extended keeping foot
externally rotated and abducted
• As femur passes over the tear in meniscus,
patient complains of pain. A definite click is
elicited under the knee
• Similar exercise with foot internally rotated
and knee adducted, if positive - tear in lateral
meniscus

119. Lateral Meniscus Testing
Medial Meniscus Testing

120.  Apley’s Compression
Test
• Patient prone
• Knee is flexed to 90 degree and
thigh fixed to examination table
• Examiner applies compression and
lateral rotation
• Pain indicates a meniscal injury
• If pain on internal rotation, lateral
meniscal tear is suspected
• If pain on external rotation, medial
meniscal tear is suspected

121. Apley’s
Distraction Test
• Patient prone
• Knee is flexed to 90 degree and
thigh fixed to examination table
• Examiner applies traction with
lateral rotation
• Pain will occur if there is
damage to the capsule or
ligaments
• No pain will occur if meniscal
tear

122.  Medial Collateral Ligament Instability
• Abduction (Valgus) Stress Test
• Apley’s Distraction Test
 Lateral Collateral Ligament Instability
• Adduction (Varus) Stress Test
• Apley’s Distraction Test

123.  Anterior Cruciate Ligament Stability
• Anterior Drawer Test
• Lachman’s Test
• Modified Lachman’s Test
• Slocum Anterior Rotary Drawer Test
• Lateral Pivot Shift Test of MacIntosh
• Jerk test of Hughston and Losee
• Flexion Rotation Drawer Test

124.  Posterior Cruciate Ligament Stability
• Posterior Drawer Test
• Posterior Sag Test (Godfrey’s Test)
• Quadriceps Active Test
• External Rotation Recurvatum Test
• Reverse Pivot Shift Sign of Jakob, Hassler and
Staeubli

125.  Meniscal Pathology
• McMurray’s Meniscal Test
• Apley’s Compression/Grinding Test

126. 126
 Lachman Test Sens 87% Spec 93%
 Anterior Drawer Sens 48% Spec 87%
 Pivot Shift Test Sens 61% Spec 97%
(Jackson JL, et al.)

127. 127
 Joint Line Tenderness Sens 76%
Spec 29%
 McMurray Test Sens 52% Spec
97%
(Jackson JL, et al.)