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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, varus, and internal rotation, then extend the knee
        • pain or pop sensation indicates lateral meniscus tear
      • place knee into flexion, valgus, 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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