HOWTRAININGMATERIAL2010/11 SESSION4

THEKNEE

HISTORY
Pain:anteriorknee,diffuse(degenerativeorinflammatorydisorders)orlocalized(mechanicaldisorderespeciallyafter
injury.(maybewithremembranceofmechanismbypatient)
Swelling:Localizedordiffuse.Timeofappearance(immediately:heamarthrosis,orlate:tornofmeniscus).Chronic:
synovitisorarthritis.
Stiffness:fluctuates?Whenitfeelsworseorbetter?(earlymorningstiffness:inflammatory;stiffnessafterperiodof
inactivity:osteoarthristis)
Locking:tornmeniscusorloosebody.(Unlocking:Obstructingobjectshasmovedandjointcannowmovefreely
again.)
Deformity:unilateralorbilateral=valgusorvarus,fixedflexionorhyperextension.(knockkneesandbandylegs
commoninchildrenandhealspontaneouslywhengrownup)
Givingway:duetomusclesweaknessormechanicaldisorder(tornmeniscusorfaultypatellarextensormechanism)
Lossoffunction:diminishingwalkingdistance,inabilitytorunanddifficultygoingupanddownsteps.

P/S:couldbereferredpainfromhipdisorder.

SIGNWITHPATIENTUPRIGHT

Valgusorvarusdeformity
Walkingpattern

SIGNWIHPATIENTLYINGSUPINE

Look
Positionofknee:valgusorvarus,partiallyflexedorhyperextended.
Swelling
Scarsorsinuses,smalllumps
Wastingofquadriceps(signofjointdisorder)
Visualimpressionmeasuringthegirthofthighatsamelevelineachlimb:fixeddistanceabovethejointlineor
ahandsbreadthabovethepatella

Feel
Warmthcomparisonbetween2knees.
Temperaturegradientbyhandrunningdownthelimb(N:lineardecreaseinwarmthfromproximaltodistal).
softtissuesandbonyoutlinesforabnormaloutlinesandlocalizedtenderness:kneeisbentandexaminersits
ontheedgeofcouchfacingtheknee;placebothhandsoverthefrontofkneetotracewithfingersthe
anatomicaloutlinesofjointmargins,patellarligament,collateralligaments,iliotibialbandandpesanserinus.
Then,thekneeisplacedflatoncouchandtheedgesofpatellofemoraljointarepalpatedwhilepushingthe
patellafirsttoonesidethentoother.
Synovialthickeningisappreciatedbyplacingkneeinextension,grasptheedgesofpatellainapinchermade
ofthumbandmiddlefinger,andtriestolifethepatellaforwards(N:graspeasilyfirmly;ifthickened
synoviumitwillslipofftheedgesofpatella)

Move
Kneeisflexeduntilthecalfmeetstheham,andextendscompletelywithasnap(crepitus:signof
patellofemoraldegenerationorwear).

HOWTRAININGMATERIAL2010/11 SESSION4
Testofintraarticularfluid
a) Crossfluctuation(onlywithlargejointeffusion):handcompressesandemptiesthesuprapatellarpouchwhile
therighthandstraddlesthefrontoftheointbelowthepatella;bysqueezingwitheachhandalternatively,a
fluidimpulseistransmittedacrossthejoint.
b) Pattelartap:suprapatellarpouchiscompressedwiththelefthand,whiletheindexfingerofrighthand
pushesthepatellasharplybackwards.Positivetest:patellacanbefeltstrikingthefemurandbouncingoff
again.
c) Bulgetest(usefulwhenverylittlefluidispresent):medialcompartmentisemptiedbypressingnthatsideof
thejointwhilstatthesametimethesuprapatellarpouchiskeptclosedbytheotherhand;thefirsthandis
thenliftedawayfromthemedialsideandmovedtothelateralside,whichisthensharplycompressed;a
distinctrippleisseenontheflattenedmedialsurface.
d) Patellarhollowtest:hollowappearslateraltopatellarligamentwhennormalkneeisflexed,anddisappears
withfurtherflexion;withexcessfluid,thehollowfillsanddisappearsatalesserangleofflexion.

Patellartest
a) Patellarfrictiontest:painelicitedbyrubbingpatellaagainstthefemoraltrochleaorbypressingagainst
patellaandaskpatienttocontractquadricepsmuscles.
b) Apprehensiontest(diagnosticofrecurrentpatellarsubluxationordislocation):pressingthepatellalaterally
withthumbwhileflexingthekneeslightlymayinduceintenseanxietyandresistancetofurthermovement.

Testforligamentousstability
a) Medialandlateralligaments:stressingthekneeintovalgusandvarusbytuckingpatientsfootunderyour
armandsupportingthekneefirmlywithonehandoneachsideofjoint;thelegisthenangulated
alternativelytowardsabductionandadduction.Thetestisperfomedat30degreesofflexionandagainatfull
extension.(tornorstretchedcollateralligamentifthereisexcessiveanglewithmediolateralmovement)
b) Cruciateligaments:examineforabnormalglidingmovementinAPplane.Withbothflexed90degreesand
thefeetrestingonthecouch,theuppertibiaisinspectedfromtheside;
ifitsupperendhasdroppedback,orcanbegentlypushedback,thisindicatesatearoftheposterior
cruciateligament(thesagsign).
Withthekneeinthesameposition,footisanchoredbytheexaminersittingonit(provideditisnot
painful);thenusingbothhands,theupperendofthetibiaisgraspedfirmlyandrockedbackwards
andforwardstoseeifthereisanyAPglide(thedrawertest)[p/s:makesurethehamstringis
relaxed].
1. Positiveanteriordrawersign:anteriorcruciatelaxity
2. Positiveposteriordrawersign:posteriorcruciatelaxity

Lachmantest:patientskneeisflexed20degrees;withonehandgraspingthelowerthighandthe
otherupperpartofleg,thejointsurfacesareshiftedbackwardsandforwardsuponeachother.If
thekneeisstable,thereshouldbenogliding.

SIGNWITHPATIENTLYINGPRONE
Scarsorlumpsinpoplitealfossa
Swelling(midline:bulgingcapsuleoroneside:bursa)
Bakercyst
Palpablelump,pulsatile?Emptiedintojoint?
Appleystest:
a) Kneeisflexedto9degreesandrotatedwhileacompressionforceisapplied.(grindingtest:ifameniscusis
torn).
b) Distractiontest:rotationisthenrepeatedwhilethelegispulledupwardswiththesurgeonskneeholdingthe
thighdown,producingincreasedpainifonlythereisligamentdamage.