CLINICAL EXAMINATION TECHNIQUES

KNEE EXAMINATION CLINICAL TECHNIQUES & TIPS

By Dr Nick Webborn, sports physician History

A full history should always be taken prior to examination. Special tests other than the basic examination of the knee may be indicated by the history and also indicate that other areas should be included in the examination eg. lumbar spine.

When the patient presents with a history of an acute injury to the knee there are sev- eral factors which will indicate the struc- tures injured and the severity of the injury: ● The mechanism of injury – contact, non-contact, foot fixed or free, flexed or extended, valgus or varus force

● The amount of pain and disability at the time – able to play on or not

● The time to onset of swelling and its location

● Symptoms and degree of disability since the injury

For chronic injuries the history is impor- tant for changes in training volume, train- ing surface or footwear. Ask about recent growth spurts in children.

Observation ● Observe patient walking – look at gait and limp

● Standing front, lateral and rear – look for genu valgum/varum, femoral/tibial torsion, patella direction and height as well as wasting, bruising, swelling, recurvatum, lordosis, pelvic tilt

● Basic biomechanics – look from rear – ask to bend knees to 45 degrees keep- ing heels on floor. Look for obvious excessive pronation. Can do more com- plete assessment if indicated later

● Lying – look for wasting, bruising, swelling, prominence of tibial tubercle, Q-angle

Examination 1. Compare normal to injured limb

2. Examine the hips prior to any exami- nation of the knee remembering that hip

8 SportEX

pathology may often present as knee pain eg. in the young – slipped femoral epiph- ysis or in the elderly - osteoarthrosis of hip

3. Effusion – it is useful to determine the presence of an effusion early in the examination. Small amounts of fluid in the knee can be determined by stroking the fluid from side to side and observ- ing for a wave of fluid. A ‘patella tap’ will only be present with larger effu- sions more readily visible

4. Active ROM – observe the patient’s active ROM and ask about symptoms during the action. Observe patella tracking. If the ROM is full then over- pressure can be applied gently to feel the end points ● Flexion – approximately 0-135º ● Extension – approximately 0-15º ● Medial and lateral tibial rotations are described but the commands are difficult for the patient to understand

5. Passive ROM – if active ROM is limited then passive movements should be checked

6. Resisted movements – may be per- formed at this stage through a range, observing power, muscle bulk, tone and any painful response. This may be per- formed after tests of ligament laxity

7. Ligament laxity – range, end point, pain (see later) ● Grade 1 – pain on stressing, no sig- nificant increase in range ● Grade 2 – pain on stressing, increased range but firm end point ● Grade 3 – may not be as painful, increased range with no end point

8. Palpation – there are numerous struc- tures which can be palpated and one is guided by the history and other find- ings but generally one would expect to palpate the following in most cases: ● Patella – position, tilt, motion (retinac-

ular tightness), facets, tendon, bursae

● Joint lines – medial and lateral for coro- nary ligament strains and meniscal cysts

● Collateral ligaments ● Other structures could include plicae, ITB, semitendinosus, semimembra- nosus, gracilis, sartorius, biceps femoris, popliteus, anserine bursa

9. Stretch – assessment of flexibility of the following should be assessed and compared to the normal: ● Hamstrings ● Quadriceps ● Calf ● Ilio-tibial band (ITB)

Ligament laxity tests MEDIAL COLLATERAL LIGAMENT Deep layers are attached to the medial meniscus. The superficial layer extends about a hands breadth below the joint line. Test by valgus force applied to knee flexed to about 20-30º which removes the influence of the postero-medial capsule and ACL which are taught in full extension of the knee (Fig.1).

Posterior oblique and posterior cruciate also contribute to stability in flexed and extended position. For the medial collat- eral ligament to be fully taut the tibia should be externally rotated.

Figure 1: Valgus stress to the medial collat- eral ligament

LATERAL COLLATERAL LIGAMENT Not attached to lateral meniscus. Test by varus force applied to knee flexed to about 20º which removes the influence of the cruciate ligaments taught in full exten-