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Physical examination of the knee

Oleh: dr. Darsuna Mardhiah


Pembimbing: dr. Deta Tanuwidjaja,Sp.KFR
Inspection
• Observe the patient’s gait
• Soft tissue swelling
• Inspect the symmetry of
muscle contours above the
knee for any visible
muscular atrophy
Anterior view, standing
• note any malalignment/
deformity :Genu valgum
/varum
• Patella : should be
symmetrical and level
• Normally, the tibia has a
slight valgus angulation in
comparison to the femur.
Inspection : Lateral view

• Patella ( alta or baja )


PALPATION
Bony prominence
1. Infrapatellar tendon
• Place your hands upon the
knee joint so that your
fingers curves around to the
posterior popliteal area
• Place your thumbs on
anterior portion of the
knee and press into the soft
tissue depressions on
either side of the
infrapatellar tendon
Palpation : Medial Aspect

2. Medial Tibia Plateau


• Push thumb inferiorly
into the soft tissue
depression until you
can feel sharp upper
edge of medial tibial
plateau
Medial aspect

3. Tibial Tubercle
• Follow the infrapatellar
tendon distally to where
it insert into the tibial
tubercle
Medial aspect
4. medial femoral condyle
• More palpable if the knee
flexed more than 90°
• The condyle is palpable
along its sharp medial
angle, proximally as far as
the superior portion of
the patella and distally to
the junction of the tibia
and femur
Medial aspect
5. Adductor tubercle
• On medial surface of
the medial femoral
condyle and move
further posteriorly
until you locate the
adductor tubercle in
the distal end of the
natural depression
between vastus
medialis and hamstring
muscle
Lateral aspect
1. Lateral femoral
condyle
• Palpable laterally
onto the sharp
edge of the lateral
femoral condyle
Lateral aspect
2. Head of fibula
• From lateral femoral
condyle, move your
thumb inferiorly and
posteriorly across the
joint line
Soft tissue palpation
1. m. quadriceps femoris
• Vastus medial and
lateral form visible
bulges on medial and
lateral sides of the knee
and easily palpable
• Defect are most often
found distally in rectus
femoris or vastus
intermedius just
proximal to the patella
• Look for any sign of
atrophy
Soft tissue palpation
1. m. quadriceps femoris
• Measuring the
circumference of each
thigh about 3 inches
above knee
Sof tissue palpation
2. Infrapatellar tendon
• Palpable to its insertion into
the tibial tubercle
• Tenderness is often here in
young individuals (Osgood-
Schlatter Syndrome)
• The infrapatellar fat pad lies
immediately posterior to
the infrapatellar tendon at
the level of joint line.
• Tenderness -> may be
evidenced of hypertrophy
or contusion of the fat pad.
Soft tissue palpation
3. Medial meniscus
• Anterior margin of
the medial meniscus
itself just barely
palpable deep within
the joint space
• When the tibia is
internally rotate, its
medial edge
becomes more
prominent and
palpable
Soft tissue palpation
4. Medial collateral
ligament
• Relocate the
medial joint line.
• As you move
,medially and
posteriorly along
the joint line, the
ligament lies
directly under your
fingertips
Soft tissue palpation
5. Sartorius, gracilis, and
semitendinosus tendons
• To palpate, stabilize the
patient’s leg by holding it
securely with your own legs.
• Cup your finger around the
knee and feel the tautness of
the tendons
• Semitendinosus tendon is the
most posterior and inferior you
can feel; gracilis lies slightly
anterior and medial to the
semitendinosus
• Wide, thick band of the muscle
just above the gracilis tendon
is the sartorius
Soft tissue palpation
6. Biceps femoris tendon
• Knee flexed, palpate
near its insertion
Soft tissue palpation

7. Iliotibial band
• Palpable to the point
where it insert to the
lateral tibial tubercle
Soft tissue palpation
8. Common peroneal nerve
• Palpable where it crosses
the neck of the fibula
• Nerve can be rolled gently
between the tip of your
finger and neck of the
fibula, slightly inferior to the
insertion of the biceps
femoris muscle.
Soft tissue palpation
10. Popliteal artery
• Because covered by the
fascia, the nerve and
the vein, it may be
difficult to feel the
popliteal pulse.
• Absence of this pulse
may be due to vascular
occlusive disease
Soft tissue palpation
11. Popliteal fossa
• Swelling in the fossa
may indicate a popliteal
cyst, palpable when the
knee extended
Test for joint stability
1. Medial collateral ligament
• Secure his ankle with one
hand, other hand around the
knee so that your thenar
eminence is against fibular
head
• Push medially against the
knee and laterally against the
ankle in an attempt to open
knee joint on inside (valgus
stress)
• palpate the medial joint line
for gapping
• When stressed of injured joint
is relieved, fell the tibia and
femur “clunk” together as
they close
Test for joint stability
2. Lateral collateral
ligament
• Push laterally against
the knee and medially
against the ankle to
open the knee joint on
lateral side (varus
stress)
Test for joint stability
3. Cruciate ligament
• Cup your hands around
his knee, with your
fingers on the area of
insertion of the medial
and lateral hamstring
and yor thumbs on
medial and lateral joint
lines
• Draw the tibia toward
you. Positive -> it slides
forward from under the
femur
• Posterior cruciate
ligament -> conversely
Special test
Mc Murray test
• Examine of meniscus tear
• Lie supine, legs flat in neutral
position. One hand hold his heel
and flex his leg fully
• Place free hand on knee joint
• Rotate the leg internally and
externally loosen the knee joint
• Push on lateral side to apply
valgus stress to the medial side of
the joint, at same time , rotating
the leg externally.
• Maintain valgus stress and
external rotation , and extend the
leg slowly as you palpate the
medial joint line
• If palpable or audible “click’
within the joint -> medial
meniscus tear
Reduction click
• Applicable for patients • Position = McMurray
with locked knee due to test
torn, dislocated, or • Flex knee while it is
heaped up meniscus rotated internally &
• To reduce the displaced externally
or torn portion of • Then rotate & extend
meniscus by clicking it leg until you hear
back into place “click”, as meniscus slips
• To unlock a locked knee back to its proper
(by torn meniscus) & position
permit full extension
Apley compression test/grinding test
• To aids dx meniscal tear
• patient lie prone with one leg
flexed to 90O
• Gently kneel on the back of his
thigh to stabilize it
• While leaning hard on the heel to
compress medial & lateral
menisci
• Rotate tibia internally &
externally on femur as you
maintain firm compression
• Positive = pain + = meniscal tear
• Pain on medial side = medial
meniscal tear
• Pain on lateral side = lateral
meniscal tear
Apley’s Distraction Test
• To distinguish between meniscal
& ligamentous problem of knee
joint
• Should follow Apley’s
compression test
• Remain in the same position after
Apley’s compression test
• Maintain stabilization of posterior
thigh
• Apply traction to leg
• While rotating tibia internally &
externally on femur
• Positive = pain + = damaged
ligaments
• Negative = pain - = only the
meniscus were torn, ligaments
not damaged
Bounce home test
• To evaluate lack of full knee
extension, secondary by torn
meniscus, loose body within
knee joint, intracapsular joint
swelling
• Patient supine
• Cup his heel on your palm
• Bend his knee into full flexion
• Passively allow knee to extend
• Positive = knee extend
completely/ bounce home
with sharp end point = normal
• Negative = knee falls short,
offering rubbery resistance to
further extension = probably
torn meniscus or other
blockage
Patellar Femoral Grinding Test
• To determine quality of
articulating surfaces of
patella and trochlear
groove of femur
• Patient supine with legs
relaxed in neutral position
• Push patella distally in
trochlear groove
• Instruct him to tighten his
quadriceps
• Palpate & offer resistance to
patella as it moves under
your fingers
• Negative = patella moves
smooth & gliding
• Positive = pain/ discomfort +
Apprehension Test for Patellar
Dislocation & Subluxation
• To determine whether patella is
prone to lateral dislocation
• If you suspect patient has
recurrent dislocating patella,
attempt to manually dislocate it
while observing his reaction face
• Patient lie supine with legs flat &
quadriceps relaxed
• Press medial border of patella
with your thumb
• Negative = little reaction = normal
• Positive = expression on patients
face becomes one of
apprehension & distress = patella
begins to dislocate
Tinel Sign
• To elicit pain from tapping
for neuromata on the end of
a cut nerve
• To the provocation of pain
on the leading edge of a
regenerating nerve
• tap area around medial side
of tibial tubercle
(infrapatellar branch
saphenous nerve)
• Positive = tenderness over
bulbous end of the severed
nerve if neuroma has
developed.
• In knee surgery, this nerve
frequently cut during
removal of medial meniscus
Test for Major Effusion
• To examine effusion on knee
joint
• When joint distended by large
effusion
• Carefully extend patient’s knee
• Instruct him to relax
quadriceps m.
• Push patella into trochlear
groove & quickly release it

• Positive = ballotable patella;


large amount of fluid under
patella first forced to the joint
sides, then flows back to its
former position, forcing patella
to rebound
Test for Minor Effusion
• Keep patient’s knee
extended
• Milk the fluid from
suprapatellar pouch &
lateral side into medial
side of knee

• Positive = Gently tap the


joint over the fluid, which
will traverse knee to
create fullness on lateral
side
TERIMA KASIH