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Special Test

Knee Physical Exam

As with other human joints, Knee Physical Exam begins with history taking, then the three examination combination Look, Feel and Move, lastly the knee special tests for every part of the knee.

History Taking

Knee problems can occur due to acute and chronic sports injuries, trauma, degenerative or inflammatory conditions. Pain is the most common symptom presented by patients, and it is important to inquire about the onset, location, severity, and factors that aggravate or relieve the pain. Other symptoms, such as joint line pain, posterior knee swelling, intermittent anteromedial knee pain, and lateral knee pain, may help identify the underlying cause of the knee problem.

Swelling around the knee can result from fluid or tissue inflammation. Inquiring about the onset of swelling, particularly its time frame since injury, can assist with diagnosis. Patients may also report symptoms of instability or “giving way” in the knee, especially during rapid changes in direction or walking on uneven ground, following an ACL rupture.

Individuals with chronic meniscal tears typically report pain during turning and repeated episodes of localized pain and a small joint effusion. When the condition presents acutely, they may exhibit limited rotation and an inability to fully extend the leg, which is accompanied by a springy block that indicates locking.

The mechanism of injury can provide valuable insights into the damage, prognosis, and management of the condition. Significant injury is likely to have been caused by a high-energy road traffic accident, a fall from a height, or other direct impact that indicates a considerable force across the knee. ACL rupture is usually a non-contact injury that occurs when the femur and upper body rotate with the foot planted. In a sporting context, the inability to continue playing, the inability to bear weight, or a “popping” or “snapping” sensation at the time of injury are all significant indicators.

Medial compartment knee OA is characterized by pain, stiffness, and varus deformity, while lateral compartment knee OA more commonly causes pain when climbing or descending stairs and episodes of “giving way.” Patellofemoral OA can present with intermittent anterior knee pain, with or without crepitus, exacerbated by climbing stairs or standing up from a seated position.

Knee Physical Exam

To perform a thorough Knee Physical Exam, it’s important to ensure adequate exposure of the patient’s lower limbs, preferably with shorts or appropriate underwear. Additionally, the knee examination should include an assessment of the hip and spine to rule out referred pain sources. A clinical gait assessment is also essential, requiring the patient to walk several steps away from the examiner and return. Furthermore, it’s recommended to assess femoral anteversion and tibial torsion during knee examination.

Look

While the patient is standing, examine their knee for varus or valgus deformities, swellings, redness, scars, muscle wasting or asymmetry, and any ankle deformities. Compare both sides, check for posterior swellings, and observe the size, position, and symmetry of the patellae.

Ask the patient to walk the length of the room and back, observing any unusual gait, such as a fixed flexion deformity, locked knee, or limping, and take note of any walking aids or orthotics used. Next, with the patient lying down, check for any fixed flexion deformities and compare quadriceps bulk with the opposite side. Measure the “true” and apparent leg lengths and determine if a true shortening exists above or below the knee.

Feel

When the patient is lying supine on a couch in a relaxed state, various important anatomical structures within the knee joint can be palpated, as much of the joint is subcutaneous.

To test for an effusion, extend the knee (details provided below).

To assess the lateral and medial patellofemoral ligaments, apply medial and lateral stress to the patella while the knee is relaxed and resting in a slightly flexed position.

When the knee is flexed at a 90° angle and the foot is resting on the couch, palpate the menisci along the medial and lateral joint lines. This may result in point tenderness over an area of meniscal pathology.

Check the MCLs and LCLs for tenderness. The LCL is best felt when the leg is in the “figure-of-four” position, with the leg crossed and the ankle resting on the opposite leg. This stresses the ligament and helps differentiate it from meniscal tenderness.

Finally, palpate the popliteal fossa behind the knee for any tenderness or swellings.

Move

The typical range for knee movement is from 0 to 140 degrees of flexion, with a few degrees of hyperflexion being considered normal. To evaluate the patient’s active flexion, ask them to flex their knee and bring their heel towards their backside. Then, assess their passive range of motion by gently flexing the knee further with the hip in flexion.

While performing flexion and extension, rest the palm of one hand on the patella to check for patellofemoral crepitus. To assess patellar tracking, have the patient sit on the edge of a couch and actively flex and extend the knee while observing or feeling the patella. Make sure to compare the extension and flexion of the affected knee with the opposite limb.

See Also: Knee Range Of Motion

Knee Special Tests

Many special tests are described to perform during the Knee Physical Exam, these include but not limited to:

  1. Anterior Drawer Test Of The Knee
  2. Pivot Shift Test
  3. Reverse Pivot Shift Test
  4. Lachman Test
  5. McMurray Test
  6. Steinman Test
  7. Thessaly Test
  8. Patellar Apprehension Test
  9. Patellar Glide Test
  10. Knee Q Angle Definition
  11. Wilson Test
  12. External Rotation Recurvatum Test
  13. Dial Test
  14. Posterior Drawer Test Of The Knee
  15. Posterior Sag Sign
  16. Varus Test Of The Knee
  17. Valgus Stress Test Of The Knee
  18. Knee Effusion Tests
  19. Patellar Tilt Test
  20. Knee Girth Measurement
  21. Popliteal Angle Test
  22. Quadriceps Active Test
  23. Waldron Test
  24. Patellar Grind Test
  25. Finochietto Sign
  26. Duck Walk Test
  27. Merke Test
  28. Payr Test
  29. Apley Grinding Test
  30. McConnell Test
  31. Hamstring Flexibility
  32. Plica Syndrome Test
  33. Ege’s Test
  34. Apley Distraction Test

In conclusion, orthopedic surgeons must conduct a thorough Knee Physical Exam to accurately diagnose knee problems. The exam includes history taking, Look, Feel, and Move, and knee special tests for every part of the knee. By doing so, orthopedic surgeons can identify the underlying cause of the knee problem and provide appropriate management.

References & More

  • Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
  • Rossi R, Dettoni F, Bruzzone M, Cottino U, D’Elicio DG, Bonasia DE. Clinical examination of the knee: know your tools for diagnosis of knee injuries. Sports Med Arthrosc Rehabil Ther Technol. 2011 Oct 28;3:25. doi: 10.1186/1758-2555-3-25. PMID: 22035381; PMCID: PMC3213012.
  • Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil. 2003 Apr;84(4):592-603. doi: 10.1053/apmr.2003.50026. PMID: 12690600.
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