The Knee

physical examination

by RYS
 Symptoms
• Pain Somebody
Help my knee ??
– Diffuse
– localized
• Swelling
– Immediate
– Some hours
• Stiffness
• Locking
• Deformity
• Limp
knee
 Observation
• Anterior view,standing

– Normally tibia has a slight valgus

• Genu varum until about 18-19 months
• Genu valgum until about 3-4 years
– Patella should symetrical and level
• Squinting patella
– Deformity :
• Valgus or knock knee
– Normal intermaleolar less than 6cm
• Varus or bowlegs
– Normal intercondyler less than 8 cm
• Analyze gait
Look knee at
– Heelstrike fully extended?
– Swingphase flexion?
• Swelling
– Intracapsuler ?
• generalized
– Extracapsuler ?
• localized
• Lateral view, standing

– Genu recurvatum (hiperextended knee)

– Patella displace
• High (alta)
• Lower (baja)
• Posterior view, standing

– Similar to those in anterior

– Baker’s cyst
• Anterior and lateral view, sitting

– Knee flexed 90 degree, feet dangling free

– Patella face forward and on distal end femur
– Displaced patella
• Frog’s eyes patella alta with lateral displaced
– Note tibial torsion
• Medial associated with genu varum
– Pigeon toed foot deformity
• Lateral for genu valgum
 Feel
Prepatellar bursa
• Warmth, intraarticular fluid
• Anterior
– Quadriceps
• wasting
– Infrapatellar tendon
• Insertion into tibial tubercle
– Prepatellar bursa Pes anserine bursa
• Housemaid knee
– Pes anserinus bursa
Deep infrapatellar bursa

Superficial infrapatellar bursa

• Medial
– Medial meniscus
• Tenderness If detached due tears coronay ligament
– Medial collateral ligament
• Move medially and posterior Medial meniscus
– Sartorius,gracillis,and semitendinosus muscle
• Position resistance against knee flexion
• Lateral
– Lateral meniscus
– Lateral collateral ligament
– Common peroneal nerve

Lateral meniscus
• Posterior
– Popliteal fossa
– Posterior tibial nerve
– Popliteal vein,artery
– Gastrocnemius muscle
 Move
• Active
– Flexion (0°-135°)
– Extension ( 0-15°)
– Internal rotation (10°)
– External rotation ( 10°)
Passive
 Joint stability
• Ligament

Collateral ligaments
• Medial collateral ligament
– Tes : abduction( VALGUS STRESS ) test
• Lateral collateral ligament
– Tes : adduction ( VARUS STRESS ) test
 Anatomy
Anterior cruciatum ligament
Posterior cruciatum ligament

Medial collateral ligament

Lateral collateral ligament
Cruciatum ligaments

• Anterior cruciatum ligament

– Knee flexed 90° hip 45 °
– Tes : ANTERIOR DRAWER TEST DRAWER TEST
– Positive (+) there is forward movement tibia
• Posterior cruciatum ligaments
– Tes : POSTERIOR DRAWER TEST
– Positive (+) reverse anterior
• LACHMAN test
– Knee flexed 20 degree
– Positive(+) soft end feel forward tibia
slope (-)

LACHMAN test
 Special test
• Meniscus injury
– Mc Murray test
• Loose tag induced palpable and audible click
– Apley’s compresion distraction test
• Grinding reproduces symptoms from meniscus torn
• Distraction from ligament damage

Mc Murray test Apley’s test

 Test for swelling
• Patellar tap test( ballotable patella )
– Positive(+) Ballotement +

• Cross fluctuation test

– Positive(+)Fluid impulse transmitted across the joint
• Bulge test
– Positive(+) Distinct ripple seen
• Patellar hollow test
– Normal : hollow +
 Neurologic
• Muscle
– Extension
• Primary extensor
– Quadriceps ,femoral nerve L234
– Flexion
• Primary flexor
– Hamstring
» Semimembranosus, sciathic L5
» Semitendinosus, sciathic L5
» Biceps femoris, sciathic S1
• Sensation

L4
L3
L2
S2
• Reflexes
– Patellar reflexs, L234
Healthy Knee Joint ?
May Be….
Terima Kasih

Uluwatu Beach
Sunset view
Bali

Ronny Sutanto
 Other special test
• Patellofemoral angle ( Q angle )
– Angle between Q muscle and patellar tendon.
– Normally 13° -18°
– <13° patella alta or chondromalacia patella
– >18° chondromalacia patella,sublux patella, genu
valgum,lateral tibial torsion.
– If knee full extended normal 8-10°
• Apprehension test
– For dislocation patella
– Knee flexed 30°, slowly passive move patella
laterally
– Positive if patient become apprehension
 Observation
• Anterior view,standing

– Normally tibia has a slight valgus

• Genu varum until about 18-19 months
• Genu valgum until about 3-4 years
– Patella should symetrical and level
• Squinting patella
– Deformity :
• Valgus or knock knee
– Normal intermaleolar less than 6cm
• Varus or bowlegs
– Normal intercondyler less than 8 cm
Tibiofemoral shaft angle normal 6º
Gravity Drawer test ( posterior sag
sign )
 Feel
Patient sit on the edge of examining table
knee flexed 90 degree relaxed,non weigthbearing.
• Medial aspect
– Medial tibial plateau
– Tibial tubercle
– Medial femoral condyle
– Adductor tubercle

• Lateral aspect
– Lateral tibial plateau
– Lateral tubercle
 – Lateral tibial plateau
– Lateral tubercle
– Lateral femoral condyle
– Lateral femoral epicondyle
– Head of the fibula

• Trochlear groove and patella

– Patella fixed in trochlear groove in flexion and mobile
in extension.
• Anterior and lateral view, sitting

– Excessive tibial torsion

-Chondromalacia patella

-Patellofemoral instability

-Fat pad entrapment

Osgood sclatter disease