KNEE
Clinical examination of the
knee
Fazal Ali
Abstract
Clinical examination of the knee starts with observing the patient
standing and then walking. On sitting, patella height, tracking and crep-
itus can be demonstrated. With the patient supine the traditional
sequence of look, feel and move of the joint is performed, followed by
testing in turn the ligamentous and capsular structures.
Keywords clinical examination; knee
Introduction
As with all joints, the knee should be examined systematically
following a standard routine. After carrying out a basic exami-
nation special tests may be added to help the diagnostic process.
Stand the patient and look
As with all other joints, except the hand, examination of the knee
should start by scrutinizing the standing patient. The symptom-
atic knee should be inspected from the front, from both lateral
and medial sides, then posteriorly (Figure 1 and Figure 2). The
last is particularly important as it may be difficult later in the
examination with the patient sitting or lying on an examination
couch.
The patients use of splints and walking aids should be noted
as they give a clue to the level of disability of the patient.
Scars are indicative of previous injury or surgery. Muscle
wasting may be indicative of disuse and/or pain.
It is essential to assess the general alignment of the lower limb
as problems of alignment or rotation can have an influence on
knee symptoms. Varus and valgus alignment may result in
abnormal forces passing through one compartment and can also
lead to patellar mal-tracking. In particular rotational abnormality
leads to mal-tracking and is a cause of anterior knee pain.
The Q angle is important. An increase may be associated with
patello-femoral symptoms. It is determined by measuring the
angle between a line drawn from the anterior superior iliac spine
to the midpoint of the patella and another line drawn from the
tibial tubercle to the midpoint of the patella. The normal is about
10 in males and 15 in females.
Swelling of the knee may be obvious with the patient standing
(but is best assessed with the patient lying on the examination
couch). Lumps may be seen; their location is a clue to the
diagnosis. For example a lump on the joint line may signify
a meniscal cyst. Anterior lumps may represent either
Fazal Ali FRCS (Tr & Orth) Consultant Orthopaedic Surgeon, Chesterfield
Royal Hospital, UK.
ORTHOPAEDICS AND TRAUMA 27:1
a housemaids knee (pre-patellar bursa) or clergymans knee
(infra-patellar bursa). Posterior lumps are most typically
a Bakers cyst or a semi-membranosus bursa (Figure 3).
Walk the patient
The patient is then assessed walking (Figure 4), comparing the
two sides. Particular points to note are the ease with which the
patient flexes the knee as he walks and the patella progression
angles and the foot progression angles. These are indicators of
the rotational profile. The patella progression angle is the angle
formed between the transverse axis of the patella and an imag-
inary sagittal line. This is usually 0 . An internal patella
progression angle is seen with squinting patellae and the
miserable malalignment syndrome. The foot progression angle
is the angle between the axis of the foot and the sagittal axis. It is
usually between 10 and 15 external. Rotational abnormalities
may be associated with diagnoses such as anterior knee pain and
patella instability.
A varus or valgus lurch should also be noted. A varus lurch is
evident when the lateral side of the knee opens on weight
bearing, and it indicates either medial compartment osteoar-
thritis or lateral ligament laxity. A valgus lurch is indicative of
either lateral compartment wear or medial ligament laxity.
Sit the patient
Patella height and tracking are best assessed with the legs over
the side of the couch rather than at any other point in the
examination (Figure 5). Thus the next stage of the examination is
carried out with the patient sitting on the edge of the couch with
their legs dependent over the side. Patella alta may be seen and
tracking can be observed when the patient is asked to extend
their legs. A positive J-sign, when the patella displaces laterally
on the terminal part of extension should be particularly sought in
tall slim females who frequently also display ligamentous hyper-
laxity.
Lie the patient down
With the patient supine on the couch the examination sequence
is look, feel, move followed by ligamentous testing and then
special tests.
Look
A careful scrutiny should look for anything missed on the earlier
more distant examination such as subtle arthroscopic portal
scars, as well as muscle wasting and effusion (Figure 6). Quad-
riceps wasting is an indicative of knee pathology. It can be
quantified by comparing the circumference of the thigh on both
sides at an equal distance from a fixed point. While traditionally
the point used has been the superior pole of the patella it is better
to use the anterior superior iliac spine.
Feel
The knee should first be examined for the presence of an effu-
sion. There are three tests for an effusion, the ballotment test, the
patella tap test and the wipe (or bulge) test (Figure 7). The bal-
lotment test is for large effusions, in which a fluid thrill is felt
across the joint if the effusion is pressed on the opposite side.
50 2013 Published by Elsevier Ltd.
 KNEE

Figure 1 Viewed from in front this patient demonstrates varus deformity Figure 2 Viewed from the side a fixed flexion deformity is evident.
of the knee, in this case due to osteoarthritis.
Ligaments
The initial assessment of the cruciate ligaments should always
This is much like testing for ascites in the abdomen. The patella start with both knees flexed to 90 and with the heels together.
tap will demonstrate a more moderate effusion. The examiner This is a very important step because it permits proper inter-
uses one hand to obliterate the supra-patellar pouch and the pretation of the anterior drawer and posterior drawer tests which
other is used to press the patella posteriorly. A tap is felt when would otherwise lack a defined starting point (Figure 10). The
fluid is displaced and the patella touches the trochlea of the relative position of the tibial tubercles is viewed from the side
femur. The wipe test is intended to show small effusions. Again and a posterior sag suggests a posterior cruciate ligament (PCL)
one hand is used to obliterate the supra-patellar pouch. The other rupture (Figure 9). If present, PCL insufficiency can be confirmed
hand is used to wipe fluid from one side of the patella tendon
followed by the other side. If there is an effusion a bulge will
appear on the opposite side.
The knee is then flexed 90 and the joint is palpated system-
atically. The knee, unlike the shoulder and the hip, is a superfi-
cial joint, therefore palpation of this joint is particularly
important. The site of tenderness usually is a good indicator of
the pathology present. For example medial joint line tenderness
may indicate a medial meniscal tear or medial compartment
osteoarthritis.

Move
Active extension should be tested first and the patient asked to
straight leg raise as this assesses the integrity of the extensor
mechanism. An extensor lag may be indicative of a chronic
quadriceps rupture and is also seen in a patellectomized patient
(Figure 8). Then active flexion should be compared to the other
side. It should be ascertained if there is further passive move-
ment of the joint if the active movement is restricted. The normal Figure 3 If the knee is not viewed from behind an abnormality such as
range of movement is 0 to at least 130 . a popliteal cyst may be missed.

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 KNEE

Figure 4 Whilst the patient walks, observe for varus or valgus lurches as Figure 5 The J sign can only be demonstrated with a patient sitting and
well as the foot and patella progression angles. hanging the leg over the side of the couch.

by the quadriceps active test in which the patient is asked to therefore any opening of the joint at 30 flexion will indicate an
attempt to straighten a bent knee held fixed by an examining isolated MCL or LCL tear.
hand on the foot and ankle of the affected leg. As the quadriceps
contracts, the posterior sag will correct. Other tests
A positive anterior drawer test indicates not only that the
The examination sequence as described so far will in most
anterior cruciate ligament (ACL) is ruptured but that there is
instances indicate a probable clinical diagnosis. Other tests can
damage to the secondary restraints such as the posterior capsule
be used to confirm the diagnosis or to look for other, less
and collaterals as well.1 The most sensitive test for ACL rupture
common, pathology such as postero-lateral corner (PLC)
is Lachmans test (Figure 11). This test is performed with the
disruption.
knee flexed at 30 to relax the secondary restraints. Laxity in this
position with a soft end point indicates an ACL rupture.
Lachmans test is for anteroeposterior stability of the ACL.
Rotational stability is assessed using the pivot shift test. This can
be painful and is therefore better performed under anaesthetic
(Figure 12). A valgus force is applied to an internally rotated tibia
which, in the presence of a ruptured ACL, subluxes the joint and
when the knee is then passively flexed the ilio-tibial band, in the
presence of an intact medial collateral ligament (MCL), reduces
the knee joint with a palpable and sometimes audible clunk.
After testing the cruciates, the collateral ligaments are tested.
The MCL is tested by applying a valgus force to the knee in full
extension and then in 20 e30 of flexion (Figure 13). To test the
lateral collateral ligament (LCL) a varus force is applied to the
knee joint in extension and 20 e30 of flexion. In either case, if
the joint opens up in extension this signifies that the collaterals
and the secondary restraints (cruciates) are probably ruptured.
Flexing the knee relaxes the cruciates and isolates the collaterals Figure 6 Scars, swelling and deformity etc should be noted.

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 KNEE

Figure 9 Posterior sag shown on viewing knees flexed to 90 from the
side.

Figure 7 Patella tap test for a moderate effusion.

Figure 10 Positive posterior drawer test.

Figure 8 Straight leg raising demonstrates a lag in this patient who has
a ruptured quadriceps.

Meniscal tests
It is not usually necessary to perform tests to diagnose meniscal
pathology as usually the diagnosis can be made from the history
and the finding of joint line tenderness.2 A meniscal tear can be
confirmed by McMurrays test or Apleys grind test and some
examiners r ask candidates to describe these tests. McMurrays
test is a provocative test in which the tibia is internally and
externally rotated whilst the knee is flexed and extended. A varus
or valgus force is also applied depending on which meniscus is
being tested. Apleys grind test is a similar. The patient lies prone
with the knee flexed to 90 and internal and external rotation of
the tibia combined with downward pressure. Figure 11 Lachmans test.

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Figure 12 Pivot shift test.
Patello-femoral tests
If the symptoms seem to be coming from the patello-femoral joint
then tests such as the patella glide test, patella apprehension test
or Clarks test can be performed and may indicate chon-
dromalacia or even arthritis. In this test the supine patient is
asked to contract their quadriceps whilst a hand is placed over
the superior pole of the patella with a slight downward pressure.
This provokes discomfort.
Figure 13 Demonstrating the MCL opening up with a valgus stress in
extension.
ORTHOPAEDICS AND TRAUMA 27:1
KNEE
Figure 14 The patella glide test in a patient with generalized ligament
laxity.
The patella glide test and the patella apprehension tests are for
patella instability. In the former the patient lies supine with the
knee extended and is asked to relax the knee. Pressure is applied
to the patella in a medial direction and in a lateral direction.
Greater than 1 cm of glide is regarded as abnormal (Figure 14). In
the patella apprehension test the lower limb is abducted over the
side of the bed and gentle laterally directed pressure applied to
the patella. The knee is then passively flexed and the patient
observed. A patient suffering from patella subluxation or dislo-
cation will exhibit apprehension!
Tests for posterolateral corner stability
If there is a history or clinical finding suggestive of a ligament
injury then the postero-lateral corner must be assessed. There are
many tests described for this condition; the two more commonly
performed ones are described here.
The varus-recurvatum test is performed by lifting the patients
leg by grasping the big toe. If there is injury to the postero-lateral
corner, the knee fall into varus and recurvatum (hyper-exten-
sion) as the tibia externally rotates on the femur. A positive result
signifies an injury not only to the posterolateral corner but also
possibly the LCL and PCL as well.3
Figure 15 The dial test showing increased external rotation in the right
side at 90 flexion.
54 2013 Published by Elsevier Ltd.

The dial test is performed with the patient prone. The legs are
grasped just proximal to the ankles and an external rotation force
applied to each leg. The degree of external rotation is compared
by looking at the position of the feet. Comparison is made with
the knees flexed to 30 and then at 90 . If there is increased
external rotation on the affected side at both 30 and 90 of
flexion then there is likely to be a combined PLC and PCL injury.4
If there is less external rotation at 90 compared to 30 in the
affected side then the injury is likely to be an isolated PLC
disruption (Figure 15). A FURTHER READING
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