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Updated: Jun 25 2021

Knee Physical Exam - Adult

  • 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 malalignment
    • 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 structures
      • pes anserine bursea
      • patellar tendon
      • quadriceps tendon
      • iliotibial band
      • collateral ligaments
      • popliteal fossa
        • pain with Baker's cyst or popliteal aneurysm
    • Swelling
      • pre-patellar bursitis
      • intra-articular effusion
        • patella balloting
        • milking
      • traumatic hemarthrosis
        • intra-articular fracture or ligament rupture
  • 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
      • dorsal pedis
      • posterior tibial
    • Reflexes
      • patellar (L4)
        • hypoactive / absent is concerning for L4 radiculopathy
        • hyperactive may indicate UMN injury
  • ROM
    • Flexion
      • 125-135 deg
    • Extension
      • 0-10 deg hyperexension
    • Rotation (stabilize femur)
      • 10-15 deg internal and external tibial rotation
  • Special Tests
    • Anterior Cruciate Ligament
      • Lachman's test
        • most sensitive test for ACL rupture
        • flex knee to 20-30 deg, translate tibia with anteriorly directed force
        • grading
          • A= firm endpoint, B= no endpoint
          • Grade 1: <5 mm translation
          • Grade 2 A/B: 5-10mm translation
          • Grade 3 A/B: >10mm translation
      • anterior drawer
        • flex knee to 90 deg, translate tibia with anteriorly directed force
        • laxity in anterior translation indicates ACL injury
      • pivot shift
        • patient is supine with the knee fully extended
        • place an internal rotation and valgus force on the proximal tibia while flexing the knee
        • clunk with flexion indicates ACL injury
          • with ACL deficient knee, the tibia starts subluxed and reduces with flexion, causing a clunk
        • ITB
          • starts anterior to the pivot point of the knee with the lateral plateua subluxed anterior (due to ACL deficiency)
          • ITB pull then becomes posterior to pivot point of the tibia during flexion causing subluxed lateral plateau to reduce with a clunk
    • Posterior Cruciate Ligament
      • posterior drawer
        • flex knee to 90 deg, posteriorly directed force on tibia
      • posterior sag
        • place the patient supine, hip at 45 deg, and knee at 90 deg
        • view the knee from the lateral position
        • posterior translation of the tibia in relation to the femur, indicates a PCL injury
      • quadriceps active
        • with the patient supine, flex the knee to 90 deg and have the patient fire their quadriceps
        • posterior subluxed tibia will translate anteriorly if PCL is deficient
      • reverse pivot shift
        • with the patient supine, flex the knee to 45 deg, ER and apply a valgus force to the proximal tibia and extend the knee
        • a clunk with knee extension indicates a PCL injury
    • Collateral Ligaments
      • valgus stress
        • medial force to knee at 0 and 30 deg
          • laxity at 30 deg indicates MCL injury
          • laxity at 0 deg indicates MCL and cruciate injury
      • varus stress
        • lateral force to knee at 0 and 30 deg
          • laxity at 30 deg indicates LCL injury
          • laxity at 0 deg indicates LCL and cruciate injury
    • Meniscus
      • joint line tenderness
        • most sensitive test for meniscal tear when pain is present
        • palpate medial and lateral joint lines
      • McMurray's test
        • place knee into flexion, and internal rotation, then extend the knee
          • pain or pop sensation indicates lateral meniscus tear
        • place knee into flexion, and external rotation, then extend the knee
          • pain or pop sensation indicates medial meniscus tear
      • Apley's compression test
        • with the patient prone, place the knee at 90 deg, then compress and rotate the leg
          • pain or pop sesation indicates meniscal tear
    • Patellofemoral Joint
      • patella displacement
        • translate patella medially or laterally
        • divide patella into 4 quadrants
          • patella should translate 2 quadrants in both directions
      • patella apprehension
        • relax the quads and place laterally directed force on patella
        • pain or apprehension would indicate MPFL or medial retinacular injury
      • J-sign
        • extend the patient's knee from a flexed position
        • maltracking noted if patella is laterally displacing in full extension
      • patella grind test
        • have the patient activate their quadriceps while placing a compression force on the patella when the knee is in full extension
        • pain would indicate patellar/trochlear OCD, chondromalacia, or arthritis
    • Extensor Mechanism
      • straight leg raise
        • patient supine, have them raise the foot off the bed and hold it in position
        • light resistance can test strength
        • inability to perform suggests quadriceps or patellar tendon injuries
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