11/13/24, 7\:06 PM Guide | Knee examination

Knee examination

Table of contents
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0\:00 6\:25

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adequately expose the patient’s legs (typically this involves the patient wearing only their underwear) and provide a blanket to
cover the patient when not being examined.
Position the patient standing for initial inspection of the lower limbs.
Ask the patient if they have any pain before proceeding with the clinical examination.

Look

General inspection

Clinical signs
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology\:
Body habitus\: obesity is a signi
Scars\: may provide clues regarding previous lower limb surgery.
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Wasting of muscles\: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron injury.
Objects or equipment
clinical status\:
Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
Walking aids\: the ability to walk can be impacted by a wide range of knee, hip and ankle pathology.
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient’s recent
medications (e.g. analgesia).

Closer inspection of the knees

Ask the patient to stand and turn in 90° increments as you inspect the knee joints from each angle for evidence of pathology.
Anterior inspection
Inspect the anterior aspect of the knees and note any abnormalities\:
Scars\: note the location of scars as they may provide clues as to the patient's previous surgical history (e.g. arthroscopy port
entry sites) or indicate previous joint trauma.
Bruising\: suggestive of recent trauma or spontaneous haemarthrosis (e.g. patients on anticoagulants or with clotting
disorders such as haemophilia).
Swelling\: note any evidence of asymmetry in the size of the knee joints that may suggest unilateral swelling (e.g. e
in
Psoriasis plaques\: typically present over extensor surfaces and important to note due to the increased risk of psoriatic
arthritis.
Patellar position\: the patella is normally located over the centre of the knee joint and any deviation from this central position
may indicate patellar dislocation or subluxation (i.e. partial dislocation).
Valgus deformity of the knee\: the tibia is turned outward in relation to the femur, resulting in the knees 'knocking' together.
Varus deformity of the knee\: the tibia is turned inward in relation to the femur, resulting in a bowlegged appearance.
Quadriceps wasting\: note any asymmetry in the bulk of the quadriceps muscles which may be due to disuse atrophy or a
lower motor neuron lesion.
Lateral inspection
Inspect the lateral aspect of the knees and note any abnormalities\:
Extension abnormalities\: knee hyperextension can occur secondary to cruciate ligament injury.
Flexion abnormalities\:
previous trauma, in
Posterior inspection
Inspect the posterior aspect of the knees and note any abnormalities\:
Scars\: again look for scars indicative of previous trauma or surgery.
Muscle wasting\: inspect for any asymmetry in the muscle bulk of the posterior compartment of the thigh or lower leg
suggestive of disuse atrophy or a lower motor neuron lesion.
Popliteal swellings\: possible causes include a Baker's cyst or popliteal aneurysm (typically pulsatile).
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Inspect the anterior aspect of the knee

Gait

Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait paying
attention to\:
Gait cycle\: note any abnormalities of the gait cycle (e.g. abnormalities in toe-o
Range of movement\: often reduced in the context of chronic joint pathology (e.g. osteoarthritis, in
Limping\: may suggest joint pain (i.e. antalgic gait), weakness or joint instability (e.g. ligamentous injury).
Leg length\: note any discrepancy which may be the cause or the result of joint pathology.
Turning\: patients with joint disease may turn slowly due to restrictions in joint range of movement or instability.
Height of steps\: high-stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy (e.g. trauma,
surgery).
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Assess gait
Gait cycle
The gait cycle has six phases\:
1. Heel-strike\: initial contact of the heel with the
2. Foot
3. Mid-stance\: the weight is aligned and balanced on this leg.
4. Heel-o
5. Toe-o
6. Swing\: the foot swings forward and comes back into contact with the
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Stages of the gait cycle (1-5) [1]

Inspection with the patient on the bed

Ask the patient to lay down on the clinical examination couch, with the headrest positioned at a 45° angle for the next part of
the assessment.
Brie
Scars
Swelling
Bruising
Quadriceps wasting
Knee joint asymmetry
Fixed
Abnormal patellar position

Feel

Temperature

With the patient still positioned supine on the clinical examination couch, with the headrest at a 45°
assess and compare knee joint temperature using the back of your hands.
angle, simultaneously
Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis,
in

Measurement of quadriceps bulk

Quadriceps wasting is commonly associated with knee joint pathology occurring secondary to disuse atrophy. Wasting will
often be apparent on inspection, however subtle wasting may only be detectable by comparative measurement of leg
circumference.
To measure the circumference of the leg in the region of the quadriceps place a measuring tape around each leg at a point
approximately 20cm above the tibial tuberosity.
Record the circumference of each leg and compare to see if there is a signi
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Palpation of the extended knee

With the patient's leg straight and relaxed, systematically palpate the joint lines and surrounding structures of each knee
joint.
Patella
other with a
1. Assess the medial and lateral border of the patella for tenderness by stabilising one side of the patella and palpating the
Tenderness may represent injury or patellofemoral arthritis.
If the patient appears apprehensive, developing tension in the muscles of the leg as you begin to mobilise the patella
(typically in the lateral direction), it may suggest a history of recurrent patellar dislocation which the patient is anticipating
(this can be formally assessed using the patellar apprehension test).
2. Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.
Medial and lateral joint lines
1. Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may
suggest\:
Fracture
Meniscal injury (e.g. meniscal tear)
Collateral ligament injury (e.g. rupture)
2. Palpate the quadriceps tendon for tenderness suggestive of tendonitis or rupture.
Assess and compare knee joint temperature
Patellar apprehension test
The patellar apprehension test is not usually performed in an OSCE, but it's useful to understand how the test is carried
out.
With the patient's knee fully extended, medial pressure is applied to the patella (to mobilise the patella laterally) whilst
simultaneously slowly
patellar instability and dislocation (as the patient is apprehensive about it recurring).

Assess for joint e

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Joint e
osteoarthritis.
Patellar tap
The patellar tap test can be used to screen for the presence of a moderate-to-large knee joint e
1. With the patient's knee fully extended, empty the suprapatellar pouch by sliding your left hand down the thigh to the upper
border of the patella.
2. Keep your left hand in position and use your right hand to press downwards on the patella with your
3. If there is
Perform patellar tap
Sweep test
The sweep test can be useful to identify small joint e
1. Position the patient supine with the leg relaxed and knee extended.
2. Empty the suprapatellar pouch by sliding your left hand down the thigh to the upper border of the patella.
3. Stroke the medial side of the knee joint to move any excess
4. Now stroke the lateral side of the knee joint which will cause any excess
side of the knee joint. This causes the appearance of a bulge or ripple on the medial side of the joint indicating the presence of
e
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Empty the suprapatellar pouch and then sweep

Palpation of the

With the patient's knee
and the popliteal fossa are often easier to assess with the knee
Patella
Palpate the patellar ligament for tenderness suggestive of tendonitis or rupture.
Medial and lateral joint lines
Palpate the medial and lateral joint lines of the knee including the collateral ligaments for evidence of tenderness which may
suggest\:
Fracture
Meniscal injury (e.g. meniscal tear)
Collateral ligament injury (e.g. rupture)
Tibial tuberosity and the head of the
Palpate the tibial tuberosity for evidence of a bony elevation and tenderness which is typically associated with Osgood-
Schlatter disease.
Palpate the head of the
Popliteal fossa
With your thumbs placed on the tibial tuberosity, curl your
swelling which may indicate the presence of a popliteal cyst (often referred to as a Baker's cyst). A pulsatile mass in the
popliteal fossa may represent a popliteal aneurysm.
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Palpate the patella tendon with the knee joint
Osgood-Schlatter disease
Osgood-Schlatter disease (OSD) involves in
and most often a
the tibial tuberosity which is worsened with activity. Risk factors include overuse, often due to sports that involve lots of
running and jumping.
Popliteal fossa pathology
There are two main types of popliteal fossa pathology to be aware of\:
A popliteal cyst (also known as a Baker's cyst) typically presents as a
swelling will feel tense when the patient's knee is extended and soft when the knee is
The cyst may also transilluminate with a pen torch.
Popliteal aneurysms are rare, but if the popliteal pulse is visible and super
Typically the popliteal pulse is only palpable on deep palpation of the popliteal fossa.

Move

The knee joint of each leg should be assessed and compared.
If the patient is known to have an issue with a particular leg, you should assess the 'normal' leg

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of
active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the
joint's movement and also look for signs of discomfort.
It's important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.
Active knee
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Normal range of movement\: 0-140°
Instructions\: Ask the patient to
"
a s y o u c a n m a n a g e .
Active knee extension
Normal range of movement\: the leg should be able to lie
Instructions\: Ask the patient to extend their knee, so that their leg is
t h e b e d .
"
" M o v e y o u r h e e l a s c l o s e t o y o u r b o t t o m
" S t r a i g h t e n y o u r l e g o u t s o t h a t i t i s

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and
allowing you to move the joint freely to assess the full range of joint movement. It's important to feel for crepitus as you move
the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint's range of
movement.
Passive knee
Normal range of movement\: 0-140°
Instructions\: Whilst supporting the patient's leg,
discomfort.
Passive knee extension
If the patient is able to lay their legs
extension. To assess for hyperextension\:
1. On the leg being assessed, hold above the ankle joint and gently lift the leg upwards.
2. Inspect the knee joint for evidence of hyperextension, with less than 10° being considered normal. Excessive knee
hyperextension may suggest pathology a
Active knee

Special tests

Cruciate ligament assessment

Posterior sag sign
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The posterior cruciate ligament (PCL) is responsible for preventing backward displacement of the tibia or forward sliding of
the femur. As a result, if the PCL is ruptured the tibia can sag posteriorly in relation to the femur and this is what is known as
the 'posterior sag sign'
.
To screen for the posterior sag sign make sure the patient is relaxed and ask them to
placed
It is important to identify this sign before proceeding to the anterior drawer test, as a posterior cruciate ligament tear can result
in a false positive anterior drawer sign. This is because an anterior movement of the tibia will occur during the anterior drawer
test due to the tibia moving from a posteriorly subluxed position back to its neutral position. This relocation of the tibia to its
neutral position may then be misinterpreted as excessive anterior movement secondary to anterior cruciate ligament laxity or
rupture.
Anterior drawer test
The anterior drawer test is used to assess the integrity of the anterior cruciate ligament.
1. Position the patient supine on the clinical examination couch with their knee
.
2. Wrap your hands around the proximal tibia with your
3. Rest your forearm down the patient's lower leg to
4. Position your thumbs over the tibial tuberosity.
5. Ask the patient to keep their legs as relaxed as tense hamstrings can mask pathology.
6. Pull the tibia anteriorly and feel for any anterior movement of the tibia on the femur. With healthy cruciate ligaments, there
should be little or no movement noted. Signi
Posterior drawer test
Repeat steps 1-5 and then push the tibia posteriorly. With healthy cruciate ligaments, there should be little or no movement
noted. Signi
Anterior drawer test
Lachman’s test
Lachman's test is an alternative test assessing for laxity or rupture of the anterior cruciate ligament (ACL). This test is rarely
required in an OSCE scenario, with the anterior drawer test being the preferred method of ACL assessment.
1. Flex the patient’s knee to 30°
.
2. Hold the lower leg with your dominant hand with your thumb on the tibial tuberosity and your
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3. With the non-dominant hand, hold the thigh just above the patella.
4. Use the dominant hand to pull the tibia forwards on the femur while the other hand stabilises the femur.
Signi
Lachman's test -
Cruciate ligaments of the knee
The cruciate ligaments of the knee include the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL).
The ACL originates from deep within the notch of the distal femur and inserts in the anterior region of the intercondylar
area of the tibia. Its primary purpose is to stabilise the knee joint by preventing anterior tibial subluxation (i.e. prevent
anterior displacement of the tibia relative to the femur). ACL injury (i.e. rupture) typically occurs when a patient lands on a
leg and then quickly pivots in the opposite direction resulting in a valgus twisting injury (e.g. in football).
The PCL originates from the lateral edge of the medial femoral condyle and attaches in the posterior region of the
intercondylar area. Its primary purpose is to stabilise the knee joint by preventing posterior tibial subluxation (i.e.
prevent posterior displacement of the tibia relative to the femur). PCL injury typically occurs secondary to hyper
the knee joint (e.g. a fall onto a
The ACL and PCL cross over each other, forming a cross shape (the Latin translation of cruciate is "cross-shaped").
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Cruciate ligament anatomy [9]

Collateral ligament assessment

Lateral collateral ligament assessment (varus stress test)
The lateral collateral ligament (LCL) assessment involves the application of a varus force to assess the integrity of the LCL of
the knee joint.
The instructions below are for examining the right knee, use the opposite hands if assessing the left knee.
1. Extend the patient's knee fully so that the leg is straight.
2. Hold the patient's ankle between your right elbow and side.
3. Position your right palm over the medial aspect of the knee.
4. Position your left palm a little lower down over the lateral aspect of the lower limb, with your
palpate the lateral knee joint line.
5. Push steadily outward with your right palm whilst pushing inwards with the left palm.
6. Whilst performing this manoeuvre, palpate the lateral knee joint line with the
With healthy collateral ligaments, there should be no abduction or adduction possible.
If there is LCL laxity or rupture your
opening up secondary to the varus force being applied.
Medial collateral ligament assessment (valgus stress test)
The medial collateral ligament (MCL) assessment involves the application of a valgus force to assess the integrity of the MCL of
the knee joint.
The instructions below are for examining the right knee, use the opposite hands if assessing the left knee.
1. Extend the patient's knee fully so that the leg is straight.
2. Hold the patient's ankle between your right elbow and side.
3. Position your left palm over the lateral aspect of the knee.
4. Position your right palm a little lower down over the medial aspect of the lower limb, with your
palpate the medial knee joint line.
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5. Push steadily inward with your left hand whilst pushing outwards with the right hand.
6. Whilst performing this manoeuvre, palpate the medial knee joint line with the
With healthy collateral ligaments, there should be no abduction or adduction possible.
If there is MCL laxity or rupture your
opening up secondary to the valgus force being applied.
Further collateral ligament assessment
If after this assessment the knee appears stable you can further assess the collateral ligaments by repeating this test with the
knee
. At this position, the cruciate ligament is not taught so minor collateral ligament laxity can be more easily
detected.
Assess lateral collateral ligaments
Collateral ligaments of the knee
The collateral ligaments of the knee include the medial collateral ligament (MCL) and the lateral collateral ligament (LCL).
The primary function of the MCL is to stabilise the knee by resisting valgus forces that would push the knee medially.
Injury of the MCL typically occurs secondary to excessive valgus force when the knee is partially
blow to the lateral aspect of the knee joint).
The primary function of the LCL is to stabilise the knee by resisting varus forces that would push the knee laterally. Injury
of the LCL typically occurs secondary to excessive varus force (e.g. a direct blow to the medial aspect of the knee joint).
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Anatomy of the collateral ligaments [9]

Assessment of the menisci

McMurray's test is used to assess the menisci for evidence of a meniscal tear. This test is not usually expected in an OSCE
scenario as it can cause signi
awareness of how and why the test is performed.
McMurray's test for assessing the medial meniscus
The instructions below are for examining the right knee, use the opposite hands if assessing the left knee.
1. With the patient supine on the clinical examination couch, passively
2. Hold the patient's right knee with your left hand, with your thumb over the medial aspect and
of the joint lines.
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