Wash hands

Introduce yourself
Explain examination (Today I'd like to examine your knees, this will involve having
to look, feel and move your knees)
Gain consent
Do you have any pain at your knees

<Stand and walk>

Look
----
Assess gait :
- Speed / Symmetry
- Heel strike / Toe off
- Antalgia

Inspection :
- Scars
- Erythema / swelling
- Assymetry
- Valgus / Varus deformity
- Quadriceps wasting
- Leg Length Discrepancy

- Inspect for popliteal swellings (Baker's Cyst / Aneurysm)

<Lie down>
- Assess joint temperature (

Palpation :
patella
Quadriceps wasting
Tibial tuberosity
Head of fibula
Medial joint lines
Lateral joint lines
Popliteal fossa
Repeat to other joint
Measure and compare quadriceps bulk (20cm above tibial tuberosity)

Patella tap
Sweep test

MOVE :
Active knee flexion
Active knee extension
Passive knee flexion (feel for crepitus)
Passive knee extension
Knee hyperextension (>10' abnormal)

Anterior drawer test (ACL)

Posterior drawer test (PCL)
Assess collateral ligaments

Neurovascular examination

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BONE SCHOOL
<LOOK>
Shoes
Walking aids

(Front)
Knee alignment :
- Physiological valgus

Patellar rotation :
- Squinting (Inwards, Increased PFA)
- Grasshopper eyes (High and lateral)

Swelling
Quads wasting
Scars

(Side)
Knee attitude :
- Flexion
- Recurvatum
- Push knees back

Step foot forward and bear weight

- examine arch

Scars

(Behind)
- Hindfoot valgus
- Swelling popliteal fossa
- Wasting of hamstrings or calf
- Level popliteal creases

(Other side)
Knee attitude :
- Flexion
- Recurvatum
- Push knees back

Step foot forward

Scars

<GAIT>
Rigid / Stiff
- decreased flexion/ extension range

Antalgic

Weak knee
- Back knee gait

Medial or lateral thrust

- valgus or varus moment about the knee

Foot progression angle

<SIT ON EDGE OF BED>

Patella tracking
- Crepitus
J-tracking
- Patellar sharply deviates laterally in terminal extension
- Or travel laterally until jumps into trochlea at midrange of flexion

<SUPINE>

-LOOK-
- Quads wasting
- Alignment
- Scars

EFFUSION :
- Swipe, ballot, tap

RANGE :
- FFD / Recurvatum / Lift foot in air
- Active extension / Quads lag
- Range of flexion bilaterally

FFD :
- Effusion
- Entrapped Meniscus
- ACL stump
- Loose body

- FEEL -

Flat :
- Extensor mechanism
- Patella
- Tibial tuberosity

Flexed :
- Joint lines, MCL, LCL
- Tibial and femoral condyles
- Popliteal Fossa

Palpate distal femur for osteochondromas

<EXAMINE LIGAMENTS>

-Collaterals-
Test at 0' and 30'
- If loose at 0, loss of secondary stabilisers

Grading :
1+ Surfaces separate 5mm or less
2+ 5 - 10 mm
3+ 10mm or more

<ACL / PCL>

- Lachmann's -
- 85% sensitive awake
- 100% sensitive asleep

Check loss of tibial step off

- Posterior sag
- MTP normally 1cm anterior to MFC

Quadriceps active
- Knee at 90'
- Stabilize foot & ask to slide foot down bed
- Normal <1mm / PCL >3mm

ANterior / Posterior drawer

- Restore tibial step off

Posterolateral drawer
- 30' IR
- Tightens PLC

Posteromedial drawer
- 15' IR
- Tightens PMC

Pivot shift
- Valgus stress with IR + axial compression
- Knee moved from extension to flexion
- In chronic ACL deficiency, the LTC is subluxed anteriorly
- At 30' it reduces backwards
- This is when ITB passes behind axis of rotation and becomes flexor
- Grade pivot glide 1 / 2 / 3

Must have 4 things

- MCL to pivot about
- Intact ITB
- No FFD
- Ability to glide (no meniscal pathology)

PCL / Posterolateral corner (PLC)

External rotation / Recurvatum

- Hold big toe and assess PLC
- Knee moves into recurvatum, tibia externally rotates & subtle varus
- Indicates PCL + PLC + LCL

Reverse pivot shift

- With valgus and ER
- Flexion to extension
- In flexion, the LTP is posteriorly subluxed
- ITB becomes extensor
- Reduces and extend
- Must compare with other side
- Present in 30% normal population especially ligamentous laxity

Dial test / Prone

- Measure thigh foot angle
- Examiner holds knees together
- Increase at 30' only - PLC
- Increase at 30' then again at 90' - PLC + PCL
- isolated PCL - No increase
- >10' compared to normal side

Meniscus
Mcmurray
- Flexion to extension
- Full IR - LM
- Full ER - MM
- I.e. Test meniscus heel is pointing towards
- POsitive test is palpable / audible thud/ click

Squat test
- Feet IR and ER

4Cs

Concealed / Popliteal fossa

Cephalad / Hip
- Rotation in flexion
- Adduction / abduction in extension

Circulation

Collagen