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THE KNEE
HISTORY
Pain: anterior knee , diffuse(degenerative or inflammatory disorders) or localized(mechanical disorder especially after
injury.(maybe with remembrance of mechanism by patient)
Swelling: Localized or diffuse. Time of appearance(immediately: heamarthrosis , or late: torn of meniscus). Chronic:
synovitis or arthritis.
Stiffness: fluctuates? When it feels worse or better? (early morning stiffness: inflammatory; stiffness after period of
inactivity: osteoarthristis)
‘Locking’: torn meniscus or loose body. (Unlocking: Obstructing objects has moved and joint can now move freely
again.)
Deformity: unilateral or bilateral = valgus or varus, fixed flexion or hyperextension. (knock‐knees and bandy‐legs
common in children and heal spontaneously when grown up)
Giving way: due to muscles weakness or mechanical disorder(torn meniscus or faulty patellar extensor mechanism)
Loss of function: diminishing walking distance, inability to run and difficulty going up and down steps.
P/S: could be referred pain from hip disorder.
SIGN WITH PATIENT UPRIGHT
Valgus or varus deformity
Walking pattern
SIGN WIH PATIENT LYING SUPINE
Look
Position of knee: valgus or varus, partially flexed or hyperextended.
Swelling
Scars or sinuses , small lumps
Wasting of quadriceps(sign of joint disorder)
Visual impression measuring the girth of thigh at same level in each limb: fixed distance above the joint line or
a hand’s breadth above the patella
Feel
Warmth comparison between 2 knees.
Temperature gradient by hand running down the limb( N: linear decrease in warmth from proximal to distal).
soft tissues and bony outlines for abnormal outlines and localized tenderness: knee is bent and examiner sits
on the edge of couch facing the knee; place both hands over the front of knee to trace with fingers the
anatomical outlines of joint margins, patellar ligament, collateral ligaments, iliotibial band and pes anserinus.
Then, the knee is placed flat on couch and the edges of patellofemoral joint are palpated while pushing the
patella first to one side then to other.
Synovial thickening is appreciated by placing knee in extension, grasp the edges of patella in a pincher made
of thumb and middle finger, and tries to life the patella forwards ( N: grasp easily firmly; if thickened
synovium it will slip off the edges of patella)
Move
Knee is flexed until the calf meets the ham, and extends completely with a snap (crepitus: sign of
patellofemoral degeneration or wear).
HOW TRAINING MATERIAL 2010/11 SESSION 4
Test of intra‐articular fluid
a) Cross‐fluctuation (only with large joint effusion):hand compresses and empties the suprapatellar pouch while
the right hand straddles the front of the oint below the patella; by squeezing with each hand alternatively, a
fluid impulse is transmitted across the joint.
b) Pattelar tap: suprapatellar pouch is compressed with the left hand, while the index finger of right hand
pushes the patella sharply backwards. Positive test: patella can be felt striking the femur and bouncing off
again.
c) Bulge test (useful when very little fluid is present): medial compartment is emptied by pressing n that side of
the joint whilst at the same time the suprapatellar pouch is kept closed by the other hand; the first hand is
then lifted away from the medial side and moved to the lateral side, which is then sharply compressed; a
distinct ripple is seen on the flattened medial surface.
d) Patellar hollow test: hollow appears lateral to patellar ligament when normal knee is flexed, and disappears
with further flexion; with excess fluid, the hollow fills and disappears at a lesser angle of flexion.
Patellar test
a) Patellar friction test: pain elicited by rubbing patella against the femoral trochlea or by pressing against
patella and ask patient to contract quadriceps muscles.
b) Apprehension test( diagnostic of recurrent patellar subluxation or dislocation): pressing the patella laterally
with thumb while flexing the knee slightly may induce intense anxiety and resistance to further movement.
Test for ligamentous stability
a) Medial and lateral ligaments: stressing the knee into valgus and varus by tucking patient’s foot under your
arm and supporting the knee firmly with one hand on each side of joint; the leg is then angulated
alternatively towards abduction and adduction. The test is perfomed at 30 degrees of flexion and again at full
extension. ( torn or stretched collateral ligament if there is excessive angle with mediolateral movement)
b) Cruciate ligaments: examine for abnormal gliding movement in AP plane. With both flexed 90 degrees and
the feet resting on the couch, the upper tibia is inspected from the side;
if it’s upper end has dropped back, or can be gently pushed back, this indicates a tear of the posterior
cruciate ligament(the ‘sag’ sign).
With the knee in the same position, foot is anchored by the examiner sitting on it (provided it is not
painful); then using both hands, the upper end of the tibia is grasped firmly and rocked backwards
and forwards to see if there is any AP glide (the drawer test) [p/s: make sure the hamstring is
relaxed].
1. Positive anterior drawer sign: anterior cruciate laxity
2. Positive posterior drawer sign: posterior cruciate laxity
Lachman test: patient’s knee is flexed 20 degrees; with one hand grasping the lower thigh and the
other upper part of leg, the joint surfaces are shifted backwards and forwards upon each other. If
the knee is stable, there should be no gliding.
SIGN WITH PATIENT LYING PRONE
Scars or lumps in popliteal fossa
Swelling( midline: bulging capsule or one side: bursa)
Baker cyst
Palpable lump , pulsatile? Emptied into joint?
Appley’s test:
a) Knee is flexed to 9‐ degrees and rotated while a compression force is applied. (grinding test: if a meniscus is
torn).
b) Distraction test: rotation is then repeated while the leg is pulled upwards with the surgeon’s knee holding the
thigh down, producing increased pain if only there is ligament damage.