HISTORY

The clinical examination of the knee should always begin with a complete history
of the symptoms and a full description of the mechanism of injury (Fig. 1). A
thorough history will guide the examiner to the essential components of the
physical examination. The examiner should defer reading the results of prior
diagnostic studies or operative reports, or both, until after the completion of

their examination to avoid any bias. Certain injuries are common to specific age
groups. For patients under the age of 35 years, conditions such as meniscal
lesions,

ligament injuries, and patellofemoral problems are more frequently encountered.

Degenerative conditions are more common among older patients. Injuries to the
extensor mechanism can also be different at various age groups. In the pediatric
population, patients tend to have distal patella tendonitis or Osgood-Schlatter
disease, whereas adolescents and young adults have more prevalent

problems with patella malalignment. In the elderly population, quadriceps

ruptures are more common after injuries to the extensor mechanism.

The mechanism of injury is extremely important in the diagnosis of knee injuries.

Most patients can accurately recall their knee position and the stresses incurred
at the time of injury. Knee injuries can occur from contact forces as well as from
falls and twisting injuries not involving contact. An audible “pop” at the time of
injury is very characteristic of injury to the anterior cruciate ligament (ACL) (1).
ACL ruptures most commonly occur during twisting or pivoting motion while the
foot is firmly planted on the ground. After injury, it is also important to know
whether the patient is able to walk and the range of motion of the knee. This will
enable the physician to determine the severity of the injury as well as rule out
intraarticular fractures. Recent changes in activity level are also important as
overuse syndromes such as iliotibial band syndrome or patella tendonitis are
commonly associated with increase in physical activity. The presence of swelling is
also helpful in the diagnosis of knee injuries. The majority of acute knee swelling
is secondary to
hemarthrosis after a tear of the ACL. An osteochondral fracture or peripheral tear
of the meniscus can also give a hemarthrosis. The blood supply to the ACL is the
middle geniculate artery. When the ACL is injured, this artery is torn most of the
time. However, the diameter of this artery is small and it may take time for the
hemarthrosis to be formed (2). The swelling may take longer if ice is applied to
the knee immediately after injury. Immediate, brisk swelling should make the
examiner suspicious for the presence of an osteochondral fracture. When the
effusion is drained, the presence of fat droplets signifies osteochondral fractures
or nondisplaced intraarticular fractures. The absence of a hemarthrosis after an
acute injury may not indicate less severe injury, as the capsule of the knee can be
torn, allowing blood to escape. Chronic The character and location of pain are
helpful in determining knee pathology. Arthritic pain is usually present in the
morning or

after a period of rest. Patients will usually describe stiffness of the joint while
getting out of a car or seat. The onset is usually more insidious. The discomfort
usually gets better as they become more active. Pain occurring secondary to
instability is usually more episodic and distinct in character. Although patients
with severe arthritis may complain of night pain, its presence should raise “red

flags” for the examiner to rule out the presence of neoplasm. Anterior knee pain
that is worse when getting up and down stairs is indicative of patellofemoral
arthritis. On the other hand, meniscal pain is very localized and is usually
unilateral. Patients sometimes report difficulty in squatting and deep knee bend
with meniscal tears.

The complaint of “locking” of the knee is common. Locking of the knee is the
inability of the knee to have full range of motion
secondary to a mechanical block. For young patients, this is common after a
displaced meniscal tear. In older patients, loose bodies
are more common. Locking of the knee should be distinguished from decrease in
range of motion secondary to pain. In the latter
condition, the patient should have full passive range of motion when they are
relaxed or when the pain is relieved. This is usually
not a mechanical phenomenon and can signify soft tissue injuries such as
osteochondral injuries or ligament pathology.
Patients can complain of “giving way” or episodes of instability. These two entities
can be caused by very different pathology.
Giving way or buckling commonly occurs with pain reflex rather than instability.
This can also be manifested by weakness or atrophy of muscles. Instability, which
is usually episodic, is mostly unpredictable. This can usually lead to falls or
feelings of the “knee is loose.” When given the history of instability, we should
note the severity of these episodes. The presence of swelling after an episode or
frequency can point to the significance of the injury.
A thorough history can allow the physician to focus on specific issues. Commonly,
the differential can be limited to several disorders and the physical examination
can assist in confirming the diagnosis.

GENERAL PHYSICAL EXAMINATION

Obtaining a thorough history from the patient will help the examiner direct their
physical examination. The sequence of the
examination will be different depending on the differential diagnosis that is
generated in the history-taking part of the examination. The physical examination
should always start with observation and inspection. Patients should be asked to
stand with their legs slightly apart while the examiner records the alignment of the
lower extremity (Fig. 2). Varus or valgus alignment of the leg should be measured
using a goniometer, as visual estimation can be difficult in some patients. The
lower extremities should be evaluated for any leg length inequalities. This can be
easily evaluated by comparing the level of the knee and the level of the iliac wing.
Step blocks of known height can be used to confirm the degree of limb length
discrepancy.
The patient's gait is then carefully examined. The examiner must identify any
abnormalities such as the presence of a medial or
lateral thrust during the stance phase of gait. The thrust may be the result of a
progressive angular deformity (secondary to arthritic changes) or chronic
ligamentous instability. A medial thrust indicates medial collateral and
posteromedial capsular
P.317 laxity; a lateral thrust indicates lateral collateral and posterolateral capsular
laxity (Fig. 3). At times, patients can have a thrust backwards into recurvatum,
signifying posterior capsular laxity.
FIG. 2. Alignment should always be measured with the patient standing in a
relaxed position. Varus or valgus alignment of the
lower limb should be measured using a goniometer.

FIG. 3. A medial thrust of the femur indicates shift of the femur medially on the
tibia through the stance phase of gait (A). A
lateral thrust indicates lateral shift of the femur (B). (From Scott WN, ed. Ligament
and extensor mechanism injuries of the
knee: diagnosis and treatment. St. Louis: CV Mosby, 1991:89, with permission.)
After gait analysis, patients should be asked to perform a deep squat; any
limitations in squatting can be related to patellofemoral or meniscal pathology.
Patients with meniscal pathology will have difficulty getting into a fully seated
position and tend to turn their trunk to keep the injured knee less flexed when
compared with the contralateral side. In contrast, patients with patellofemoral
arthritis will complain of anterior knee pain during the squatting motion when the
joint is being loaded.

FIG. 4. A major effusion can be easily detected by “balloting” the patella over the
femoral groove. (From Hopperfield S.
Physical examination of the spine and extrem-ity. New York: Appleton-Century-
Crofts, 1976: 195, with permission.)
The patient should then be examined supine on a comfortable examination table.
At times, the uninjured knee may be swollen or
locked and cannot be fully extended. In these instances, a pillow can be placed
behind the knee to relax the knee. The pillow should
also be placed behind the uninjured knee so that both knees can be inspected at the
same angle. The examination should first be
directed to the uninjured limb. As there is little variation between the right and left
knee in joint motion and laxity before injury,
the uninjured knee can serve as a good control for the injured side. Examining the
uninjured side first can also gain confidence from the patient. Examination of
every joint should begin with inspection and palpation, followed by specific
provocative examinations. With the patient supine, the thigh can be assessed for
quadriceps atrophy. Quadriceps atrophy can occur rapidly after a significant injury
and after immobilization. A simple method to measure thigh circumference in a
reproducible manner is to measure the circumference at the same point above the
patella in each and every knee.
After examining the uninjured knee, the injured knee should first be inspected for
its skin integrity and any areas of ecchymosis.
The presence or absence of any effusion can be noted. The effusion is often visible
as fullness or swelling in the suprapatellar pouch. The effusion is confirmed by
balloting the patella onto the femoral groove (Fig. 4). Smaller amounts of fluid in
the knee may not separate the patella from the patella and can be harder to detect.
One method is to milk the fluid upward into the suprapatellar pouch; the other
hand can then be placed over the suprapatellar pouch, feeling for the separation of
the patella away from the femur (Fig. 5). The effusion can be quantitated, and this
can help differentiate subtle from significant pathologic conditions. Also, the
quantity can be used to follow the progression of the condition.
The active and passive range of motion of the knee should be noted during the
examination (Fig. 6). Range of motion should also be compared with the uninjured
knee; the examiner should also note any type of hyperextension of the knee. Loss
of active and passive range of motion can signify a chronic problem with
contractures or a mechanical block, whereas loss of active motion only can signify
pain or weakness. Lack of active full extension can be secondary to locking,
effusion, or pain. Disruption of the extensor mechanism can give an extensor lag.
If the effusion is thought to be the cause of lack of extension, the knee can be
aspirated, and the range of motion can be repeated. Lack of active full flexion can
be secondary to meniscal pathology or loose body.

FIG. 5. Smaller amount of effusion can be detected by “milking” the effusion into
the suprapatellar region and appreciating the
separation or fullness between the patella and the femur.

After inspecting the knee, the examiner should then proceed to palpation of the
knee. Palpation should be gentle but thorough.
Palpation around the patella can identify facet tenderness or insertional tenderness
of the patella tendon and quadriceps tendon.
Injury along the collateral ligaments can best be identified with pain elicited along
its course and at their attachments. Palpation of the joint line is done medially and
laterally to elicit pain that can be caused by meniscal injury (Fig. 7). Tenderness at
the tibial
tubercle can indicate Osgood-Schlatter disease. Osteochondritis dissecans of the
knee can also be diagnosed with a positive Wilson's sign, pain with internal
rotation, and extension of the knee that is relieved with external rotation (3)

FIG. 6. Active and passive range of motion of the patient should be performed with the
patient lying on an examination table.
Range of motion should always be compared with uninjured side. An examiner should
always check for hyperextension (A)
and flexion (B) in all patients.
After history taking, inspection, and palpation, the examiner should have some
idea of what is the likely source of the patient's
problem. More specific testing of the affected areas can then be performed. These
particular tests are described in the following
section of the chapter.