Examination of Knee Presenter : Dr.Subodh Pathak

The knee is a Hinge type synovial joint, which is composed of three functional compartments:

Femoropatellar Medial femorotibial articulationLateral femorotibial articulation

Anatomy of Knee joint

KNEE IS A COMPLEX JOINT:

1.HINGE TYPE: flexion extension of about 0-140 degree possible.2.PIVOT TYPE: provides rotational movement of about 5-25degree.

Femur: Lateral and Medial condyle

Tibia: Tibial condyles are separated by the intercondylar eminence

Patella

Articular Surfaces

On the medial side, the femur meets the tibia like a wheel on a flat surface, whereas on the lateral side, it is like a wheel on a dome.

Lateral condyle lies more directly in line with the shaft,slightly anterior , and is Smaller.

Medial condyle is in line with the femoral head, slightly posterior and is Larger, extending further distally.

Hence the distal femur remains essentially horizontal.

Tibial PlateauIs asymmetricalMedial tibial plateau: Longer in AP direction.

Lateral tibial plateau is smaller in AP direction but has a larger articular cartilage.Tibial plateau slopes posteriorly approx. 7 to 100.

PATELLA Inverted triangle with apex

pointing inferiorly. Posterior articulating surface

has a vertical ridge dividing it equally into medial and lateral facets.

2nd medial vertical ridge that forms the odd facet.

Functions primarily as the pulley to the quadriceps.

Femoral sulcus on the anterior aspect of distal femur. Has a central groove that corresponds to vertical ridge of patella.

Range of motion of flexion / extensionACTION ( flexion / extension ) RANGE IN DEGREES

Normal range 130 – 140

Squatting Upto 160

Normal gait 60-70

Ascending stairs 80

Sitting down / rising from a chair 90

Movements

J shaped curve around Femoral condyles

Intracapsular LigamentsACLPCLTransverse ligament Anterior meniscofemoral ligamentPosterior Meniscofemoral LigamentMeniscotibial ligaments

Ligaments

Extracapsular LigamentsPatellar ligament 

Medial collateral Ligament

Lateral Collateral ligament

Oblique popliteal Ligament

Transverse popliteal Ligament

Arises in front of intercondylar eminence of tibia

Inserts into semicircular area on the posteromedial aspect of lateral femoral condyle.

33mm long , 11 mm broad. It twists about 90 from tibial to femoral

insertion. 2 Bundles: Anteromedial (tense with flexion) Posterolateral (tense in extension)

Anterior Cruciate Ligament

M L

Function

Resists anterior tibial translation

Prevent hyper extension

Secondary restrain to both valgus and varus

ACL is taut between – full extension and 20 degree( lachmans test)

Relax between 30-40 degree ( max at 40)

Tension of ACL raises again at 70 to 90 degree( anterior drawer test)

Arises from posterior margin of tibia inferior to tibial articular surface inserted into lateral wall of medial epicondyle of femur.

Two bundles : Anterolateral (tense with flexion) Posteromedial (tense in

extension)* PCL is more vertically oriented,

and is the axis around which rotation of knee occurs.

Posterior Cruciate Ligament

Serves as the primary restraint to posterior translation

Restrains force better at flexion.maximally at 75 to 900 flexion.

Also restrains varus and valgus stresses.

Extension Flextion

Menisci

Menisci are crescentic laminae deepening the articulation of the tibial surfaces that receive the femur. Their peripheral attached borders are thick and convex, their free borders thin and concave.

Peripheral zone is vascularized by capillary loops from the fibrous capsule and synovial membrane

Inner regions are avascular

MEDIAL MENISCILATERAL MENISCI

C- shaped

Larger exposed surface hence greater susceptibility to compressive loads.

Genu varum increases force

Greater ligamentous and capsular restraints(deep portion of the MCL) , limiting translation(more susceptible to injury)

Semimembranosus muscle is attached.

4/5th of a circle Covers a greater % of

area

More medially, part of the tendon of popliteus is attached to the lateral meniscus, and so mobility of its posterior horn may be controlled by the meniscofemoral ligaments and popliteus

Importance:1. Improves the

congruence2. Distribution of

weight bearing forces

3. Reducing friction4. Serving as shock

absorbers5. Prevents capsular

and synovial impingement.

BURSAE------14ANTERIOR LATERAL MEDIAL

Suprapatellar Lateral gastrocnemius [subtendinous] bursa)

 Medial gastrocnemius [subtendinous] bursa 

prepatellar fibular (LCL-biceps) Anserine(MCL-Anserine)

Deep infrapatellar Fibulopopliteal(LCL-pop) Bursa semimembranosa(MCL-Semimem)

Superficial infrapatellar Subpopliteal(pop –lat Condyle of femur)

Between semimembranosus tendon and head of tibia.

Pretibial(tibial tuberosity-Skin)

Between semimembranosus and semitendinosus.

When???

How???

Symptoms??

Level of Activity??

History Taking……..Injury??

◦ Position of the knee in respect to body as a whole at the time of injury

Mechanism of injury

Historical clues Noncontact injury with “pop” ACL tear

Contact injury with “pop” MCL or LCL tear, meniscus tear, fracture

Acute swelling ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation

Lateral blow to the knee MCL tear

Medial blow to the knee LCL tear

Knee “gave out” or “buckled” ACL tear, patellar dislocation

Fall onto a flexed knee PCL tear

Symptoms

Character? Severity? Exact site of pain? Time? Pain at night -Inflammatory cause--

mechanical in origin. Pain when going up or down stairs, or aching

in positions where the knee is kept flexed for prolonged periods of time (car journeys, visits to the cinema), ---Patellar problems,

PAIN

Pain when going up or down stairs, or aching in positions where the knee is kept flexed for prolonged periods of time (car journeys, visits to the cinema) ---Patellar problems

Pain that occurs when the knee is hyperflexed (meniscal pathology)

Onset of Pain◦ Date of injury or when symptoms started

Location of pain*◦ Anterior ◦ Medial ◦ Lateral ◦ Posterior

• Anterior – Patellofemoral syndrome, bursitis, Osgood-Schlatter’s disease, patellar tendinitis, patellar fracture

• Medial – meniscus, MCL, OA, pes anserine bursitis

• Lateral – Meniscus, LCL, OA, iliotibial band friction syndrome, fibular head dysfunction

• Posterior – hamstring injury, tear of posterior horn of medial or lateral meniscus, Baker’s cyst, neurovascular injury (popliteal artery or nerve)

Differential diagnosis by LOCATION:

Historical Clues to Knee Injury Diagnoses

LookFeel Move

Examination

Notes on Ottawa Knee Rules 1. Age 55 or older

2. Point tenderness at patella (no bone tenderness of knee other than patella) 3. Tenderness at head of fibula.4. Knee cannot be flexed to 90 degrees5. Patient unable to bear weight for four steps immediately and in the emergency

department or office.

Tips for Accurate Usage:Tenderness of patella only counts if it is the only area of the bone tenderness in the knee Inability to bear weight means patient is unable to transfer weight twice onto each leg regardless of

limpingSensitivity - 100%Negative predictive value 100%Specificity 49%

Compared with examination, MRI more sensitive for ligamentous and meniscal damage but less specific.

Expose both lower limbs Postions

◦Standing ◦Seated position◦Supine position◦Prone position

Inspection:

Anteriorly

Laterally Medially

Muscle wasting

Popliteal fossa

Alignment

Standing

Swelling Always indicative of a genuine lesion of the joint◦Causes Infective Traumatic - effusion – hemarthrosis,

dislocated patella, knee dislocation , fracture

Degenerative Bursitis Tumors Popliteal aneurysm

Surface Anatomy (Ant )Inspection

Hollow

PATELLA

•Appears hollow on either side of patella•There is a slight indentation above the patella

• A small amount of fluid will make these hollow-appearing areas disappear. Larger effusions are most conspicuous as a fullness proximal to the patella.

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Palpation – Anterior*Patella:

Lateral and Medial Patellar Facets

Superior AndInferior Patellar Facets

Patellar Tendon**

Lateral Fat PadMedial Fat Pat

Patella is Normally oval

Presence of BIPARTITE PATELLA ,distortion of this shape may be visible.

Manifested as Protruding prominence at the supralateral aspect of patella

The infrapatellar fat pad, also known as Hoffa's fat pad, is a cylindrical piece of fat that is situated under and behind the patella.

Infrapatellar fat pad

Patellar Tendon inserts on bony prominence called Tibial Tubercle

Prominece enlarged in Osgood–Schlatter disease

Proximal Tibia

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Surface Anatomy - Medial

Medial FemoralCondyle

Patella

JointLine

MedialTibial Condyle

TibialTuberosity

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Palpation - Medial

Medial Collateral Ligament (MCL)*

Pes anserine bursa**

Medial joint line

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Palpation – Lateral*

Lateral joint line

Lateral Collateral Ligament (LCL)**

Chronic Lateral meniscal tear---a localised band of synovitis may occur along lateral joint line creating a charactersitic buldge.

Medially—Semimembranous(A) &

Semitendinious(B)

Laterally—Biceps Femoris(C)

D=Common peroneal Nerve E=Medial head of

Gastrocnemius F=Lateral Head

Popliteal Fossa

Look in the thigh Quadriceps wasting Vastus medialis

wasting Very often seen after

an old injury to the meniscus.

Muscle Wasting

Anterior Prepatellar Bursitis Infrapatellar Bursitis Suprapatellar bursitisMedially Pes anserine bursitis Posteriorly Morrant Bakers cyst Popliteal Aneurysm Semimembranous Bursitis

Cystic Swelling Around the Knee

Housemaid's knee Egg like swelling Anterior to Patella Nodule Formation can be seen or

palpated in prepatellar bursa in chronic inflammation

Prepatellar Bursitis

Clergyman's knee

Infrapatellar bursitis

Occurrence of pes anserine bursitis commonly is characterized by pain, especially when climbing stairs, tenderness, and local swelling.

Pes Anserine Bursitis

A Baker's cyst, also known as a popliteal cyst, is a benign swelling of the semimembranous or more rarely some other synovial bursa found behind the knee joint

Best Seen in patient prone and relaxed

Popliteal Cysts

Superficial palpation:TemperatureSkin SurfaceElasticity of skinCheck for Swelling or Sinus

Palpation

A mark on the knee is made 10-15cms above the suprapatellar margin.

Compare with Normal.

Thigh Circumference

Doughy or Earthworms filled in bag

Usually its Warm

The edge of synovial swelling can be palpated and rolled under the fingers

Swelling cannot be Squeezed out to another compartment of the knee jt.

Trans illumination is Negative

Features of Synovial Swelling

With the left hand to squeeze any fluid fromthe pouch into the joint. With the other hand the patella is then tapped sharply backwards onto the femoral condyles. In a positive test the patella can be felt striking the femur and bouncing off again.

The Patellar tap

Patient in Supine positionKnee in 10 degree Flextion Done when very little

fluid in the joint With the help of palm

milk the potential effusion from medial side to Lateral Side or suprapatellar region.

Reverse manoeuvre on lateral side.

If rapid filling occurs Buldge test is positive.

Patellar Buldge Test

Normally Physiologic Valgus Alignment of about 7 degree in Females and 5 degree in males

ALIGNMENT

Post Polio paralysis

Genu Recurvatum

 Fixed Flexion Deformity Simple screening method

Supine postion, passive, 10cm from couch patient's feet are braced against the examiner's

abdomen, may seek to reduce the flexion deformity by

pressing down on the patient's knees

In Prone◦ Firm table◦ Edge ◦ Distance between two heels ◦ In cms◦ 1cm = 1 degrees

PATELLA Position Palpating the

borders Tenderness Mobility Tracking Q angle Tests

◦ Apprehension ◦ Grind test

Q – angle / quadriceps angle Net effect of pull of

quadriceps and the patellar tendon is clinically assessed by the Q angle.

It helps predict the tendency of patella to subluxate.

Normal 10 – 150 In full extension.

An increase in Q angle leads to increase in lateral force of patella. leading to subluxation/ dislocation.

- Q angle is increased by:           - genu valgum           - increased femoral anteversion           - external tibial torsion           - laterally positioned tibial tuberosity           - tight lateral retinaculum

Tubercle-sulcus angle

normally ◦ <8° in women and ◦ <5° in men

Figure 6-22. Tubercle-sulcus angle.

PATELLOFEMORAL JOINT

In a fully extended knee the patella lies on the femoral sulcus.

In this position the patella is not in the intercondylar groove, joint congruency is less hence instability.

So Higher the patella higher the instability

INSALL SALVATI INDEX Ratio of length of patellar tendon to length

of the patella. Normally = 1/1 Markedly long tendon (high patella)-

“PATELLA ALTA.” In patella alta the patella is is proximal to

the lateral lip of the femoral sulcus thus high chances of subluxation.

Low lying patella – “PATELLA BAJA”

The traditional number used to TL:PL is < 1.2 (between 0.8 and 1.2), up to 0.74 to 1.50.

patella alta : > 1.2 (>1.5)patella baja : < 0.8 (<0.74)

PATELLA MALALIGNMENT Normally in sitting position, the patella

points forwards.in patella Alta it faces upwards.

In sitting if patient with subluxation / rotation malalingnment extends the knee, a sudden lateral displacement is seen called “ J sign / J tracking ”

Patellar TestsPatellar Grind test Passive—Crunching Sensation transmitted through

patella Active

Step up-Step Down test Remb: Hypertrophied Synovial folds may

produce a much Softer popping Sensation

Dynamic Patellar tracking Knee at 90 deg to full

extension

Shifts laterally at terminal extension

Excess lateral shift

/Lateral tilt morked marked/tilt terminally indicates patellar instability

Figure 6-66. Assessing patellar tracking.

Patient Supine Grasp the Sympt limb at

ankle and allow the knee to be Flexed over the Side of table.

Push the patella as far laterally as possible

Then slowly flex the knee with other hand

Creates an APPREHENSION that episode of instability is imminent

Patellar Apprehension Test

SPECIAL TESTS

Abduction (Valgus) Stress Test==For MCL

• Patient supine• Normal extremity should be examined

initially to gain confidence and to determine patient’s normal ligamentous tightness

• Flex knee approximately 30 degrees• Place one hand on lateral aspect of knee

and the other supporting the ankle. Gently apply valgus stress to knee while the hand at the ankle externally rotates the leg slightly. Bring the knee into full extension and repeat

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Valgus Stress Test for MCL*

Note Direction Of Forces

• Alternatively, examiner can place patient’s ankle in axilla, place one hand on each side of the knee near the joint line, and then gently produce a rocking motion

• Performed in a similar manner with varus stress applied to knee joint

• Tested in flexion - posterior capsule is relaxed- cruciates are relaxed- ligaments are stretched• If significant varus and valgus instability is

produced - cruciate ligament disruption in addition to collateral ligament disruption

Adduction (Varus) Stress Test

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Varus Stress Test for LCL*

Note direction of forces

GRADES OF INSTABILITY 1st degree – Joint surfaces separated 5 mm

or less. Indicates tear to minimum number of fibers with no instability

2nd degree – Separation 5 to 10 mm. Indicates disruption of more fibers with more loss of function with mild to moderate instability

3rd degree – Separation > 10 mm. Indicates complete disruption with marked instability

Anterior Drawer Test• Patient supine

• Flex hip to 45 degrees and knee to 90 degrees, placing foot on the tabletop (to relax hamstrings)

• Sit on dorsum of patient’s foot to stabilize it, place both hands behind the knee. Thumb on anterior joint line

• Repeatedly pull and push the proximal part of leg anteriorly and posteriorly

• Drawer of 6-8 mm is positive

• Done in 3 positions – neutral, 30 degree external rotation and 30 degree internal rotation

• If equal drawer is seen in neutral and external rotation position – ACL and posteromedial portion of joint capsule (with MCL) tear

• If equal drawer is seen in neutral and internal rotation position – ACL and posterolateral portion of joint capsule (with LCL) tear

Lachman’s Test• Patient supine with knee

flexed to 10-15 degrees.• One hand stabilizes

femur while the other grips proximal tibia

• Thumb on anteromedial joint margin

• Lifting force-- the tibia in relation to the femur is palpated by thumb

• Anterior translation of the tibia indicates a positive test

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Lachman Test View from lateral aspect*

Note direction of forces

Stabilized Lachman’s Test• Examiner’s thigh is kept under patient’s

knee• In painful conditions

Modified Lachman’s Test• Leg is supported by the table• If the athlete's leg is too large to hold up or

the examiners hands are too small to get a good grip

Posterior Drawer Test• Performed in a similar manner. Posterior

force is applied to proximal tibia

• Place both knees in similar position

• Thumb on each anteromedial joint line

• Loss of the normal 1 cm anterior step-off of medial tibial plateau with respect to the medial femoral condyle indicates torn PCL

Posterior Drawer test

If patient starts to raise the foot from this position, pull of quadriceps first displaces tibia anteriorly into neutral position until anterior cruciate ligament is tight . Only then is foot raised from table

Posterior Sag Test (Godfrey’s Test)

• Both hips and knees are flexed to 90 degrees

• Heels supported by examiners hands• Sagging of tibia posteriorly due to effect of

gravity is noted• Lateral observation is required

Quadriceps Active Test

• Patient supine, knee 90 degrees as in drawer test

• If PCL is ruptured, the tibia sags into posterior subluxation

• Gentle quadriceps contraction to shift tibia without extending knee

• An anterior shift of the tibia of 2 mm or more is seen if test is positive

Contraction of the quadriceps muscle in a knee with a posterior cruciate ligament deficiency results in an anterior shift of the tibia of 2 mm or more.

ROTARY TESTS

Slocum Anterior Rotary Drawer Test

• This is done as in anterior drawer with 3 positions – neutral rotation, 15 degree internal rotation (PCL is taut) & 30 degree external rotation

• A positive anterior drawer test in neutral tibial rotation that is accentuated in 30 degrees of external tibial rotation and reduced when performed in 15 degrees of internal tibial rotation, indicates anteromedial rotary instability

• Opposite indicates anterolateral rotary instability

Pivot Shift Test of Macintosh( E----F)"When I pivot, my knee shifts”• Done for Anterolateral rotary instability• Patient supine, knee extended• Tibia is internally rotated while valgus stress is

exerted over knee• In this position, tibia is subluxed anteriorly• Knee is flexed to 30 degrees—Anteriorly

Subluxated tibia spontaneously reduces into its Normal Position Resulting is sudden visible JUMP

• Isolated tear of the anterior cruciate ligament produces small subluxation. Greater subluxation occurs due to involvement of lateral capsular complex or semimembranosus

• Elicited while moving the knee to flexion(30) with internal rotation and valgus

• Best place to watch the Jump is Gerdy tubercle

Reverse Pivot Shift Sign of Jakob, Hassler and Staeubli

• (F-----E)• Done for Posterolateral rotary instability• Patient supine, knee 90 degrees flexed• Tibia is externally rotated while valgus stress is

exerted over flexed knee• Causes lateral tibia to subluxate posteriorly

(seen as posterior sag) in relation to lateral femoral condyle

• Knee is extended

• As the knee approaches 20* of flextion Lateral tibial plateau moves anteriorly in a jerk like shift from a position of posterior subluxation and external rotation into a position of reduction and neutral rotation

• Elicited while moving the knee to extension with external rotation and valgus

Jerk test of Hughston and Losee

• Done for anterolateral rotary instability• Patient supine, knee 90 degree flexed• Tibia is internally rotated while valgus

stress is exerted over knee• Knee is extended gradually• When positive, lateral tibia subluxates

forward in form of sudden jerk at 30 degree of flexion

• Elicited while moving the knee to extension with internal rotation and valgus

Flexion Rotation Drawer Test Done for Anterolateral rotary instability• Patient supine, knee extended

• Lift the leg upward, allowing the femur to fall back and externally rotate the leg

• Anterolateral tibial subluxation is the starting position for this test

• Knee is flexed, the tibia moves backward and the femur rotates internally, causing the joint to reduce when the test is positive

External Rotation Recurvatum Test• Done for posterolateral rotary instability and PCL• Patient supine, knee is moved from 10 degree

flexion to maximal extension• External rotation and recurvatum is noted• If excessive with varus deformity, test is positive

TESTS FOR MENISCIMcMurray’s Test

• Patient supine• To check medial meniscus, examiner stands on

affected side• Grasps foot firmly in one hand and knee in

other hand. Knee joint is completely fixed• Foot rotated externally and abduction stress

given at knee

• Joint is slowly extended keeping foot externally rotated and abducted

• As femur passes over the tear in meniscus, patient complains of pain. A definite click is elicited under the knee

• Similar exercise with foot internally rotated and knee adducted, if positive - tear in lateral meniscus

Lateral Meniscus Testing

Medial Meniscus Testing

Apley’s Compression Test

• Patient prone• Knee is flexed to 90 degree and

thigh fixed to examination table• Examiner applies compression

and lateral rotation• Pain indicates a meniscal injury• If pain on internal rotation, lateral

meniscal tear is suspected• If pain on external rotation, medial

meniscal tear is suspected

Apley’s Distraction Test

• Patient prone• Knee is flexed to 90 degree

and thigh fixed to examination table

• Examiner applies traction with lateral rotation

• Pain will occur if there is damage to the capsule or ligaments

• No pain will occur if meniscal tear

SUMMARY OF CLINICAL TESTS

Medial Collateral Ligament Instability• Abduction (Valgus) Stress Test• Apley’s Distraction Test

Lateral Collateral Ligament Instability• Adduction (Varus) Stress Test• Apley’s Distraction Test

Anterior Cruciate Ligament Stability• Anterior Drawer Test• Lachman’s Test• Modified Lachman’s Test• Slocum Anterior Rotary Drawer Test• Lateral Pivot Shift Test of MacIntosh• Jerk test of Hughston and Losee• Flexion Rotation Drawer Test

Posterior Cruciate Ligament Stability• Posterior Drawer Test• Posterior Sag Test (Godfrey’s Test)• Quadriceps Active Test• External Rotation Recurvatum Test• Reverse Pivot Shift Sign of Jakob, Hassler and

Staeubli

Meniscal Pathology• McMurray’s Meniscal Test• Apley’s Compression/Grinding Test

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Review of Evidence – ACL*

Lachman Test Sens 87% Spec 93% Anterior Drawer Sens 48% Spec 87% Pivot Shift Test Sens 61% Spec 97%

(Jackson JL, et al.)

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Review of Evidence - Meniscus

Joint Line Tenderness Sens 76% Spec 29%

McMurray Test Sens 52% Spec 97%

(Jackson JL, et al.)

THANK YOU