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Examination of Knee

- Discussion:
    - serial diagnostic exam should take into consideration static deformities of the lower extremities, gait, ROM, tenderness, and knee 
    - in the child w/ a painful knee, it is essential to closely examine the hip as hip pathology can refer pain to the hip;

- Examination:
    - Gait:
    - Effusion:
          - Bursitis
          - Hemarthrosis;
    - ROM:
          - Nl functional ROM: 3 deg of hyperext and 140 deg of flexion;
          - ADL ROM: for routines ADLs need 115 deg of flexion;
          - acute extension block:
                - may be due to bucket handle meniscus tear, ACL tear (from interposition of the ACL between the femur and the tibia), or 
                       from fat pad adhesions to a torn ACL;
                - as is pointed out by Shelbourne KD (1996), an acute knee block associated with an ACL tear is
                       usually due to interposition of the ACL between the femur and tibia in the intercondylar notch;
                       - this author emphasizes, the need to perform dedicated physical therapy to restore motion;
                - physical therapy should consists of ROM, stretching, and patellar mobilization;
                - references:
                       - Review of “Acute extension block caused by anterior cruciate ligament tear: A case report” Shelbourne KD.  Arthroscopy 1996:492
                       - The locked knee
                       - Fat pad adhesion to partially torn anterior cruciate ligament: a cause of knee locking.  - Tenderness:
          - popliteal tenderness:
                - deep venous thrombosis
                - popliteal cyst
                       - pain radiating down the medial gastrocnemius can represent a ruptured Baker's cyst;
                - medial gastrocnemius head rupture;
                - popliteal artery aneuysm; (see popliteal artery);
                       - Ruptured popliteal artery aneurysm. An insidious complication.
          - joint line tenderness:
                - meniscal tear:
                       - McMurray test
                       - Squat Test:
                               - attempts to reproduce meniscal symptoms by performing repetitions of a full squat with the feet and legs alternately
                                      internally and externally rotated as the squat is performed, testing the lateral and medial menisci, respectively;
                               - w/ the patient in the squat position, look for joint line tenderness;
                - differential dx: (peri-articular tenderness)
                       - medial:
                               - semimembranosus-tibial collateral ligament bursitis;
                               - MCL and/or post oblique ligament tears;
                       - lateral:
                               - LCL tears;
                               - Popliteus Tendinitis
                       - femoral condyle tenderness (chondral defect)
                       - masses in popliteal fossa;
                       - extensor mechanism:
                       - quad tendon
         - patellar tendon
                - patella
                - tenderness along margins of patella, with knee in extension
                - feel for tenderness of the back of the patella by pushing the patella alternately to either side with one hand, while the other is used 
                       to feel the exposed posterior surface of the patella;
    - Stability:
            - ACL:
                  - Lachman
                  - Pivot shift
                  - Anterior Drawer
                  - Internal Rotation
                  - Clunk Test
                  - Losee Test
                  - Anterolateral Rotatory Instability
                  - Anteromedial Rotatory Stability:
            - PCL Exam:
                  - need to rule out posterolateral rotary instability w/ reversed pivot shift

    - Varus and Valgus Stress Test:
            - MCL and post oblique ligament tears;
            - LCL tears;
                  - need to rule out posterolateral rotary instability:
                  - arcuate complex

    - Examination of the Patellofemoral Joint

The accuracy of the clinical knee examination documented by arthroscopy. A prospective study.

Femoral morphometry and anterior knee pain.

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