Knee Examination

Effusion

For smaller Effusion

1. Fullness in a para-patellar fossa in flexion
2. Bulge Sign
3. Patella Hollow test

Moderate Effusion

1. Patella tap

Large effusion

1. Cross Fluctuation

Bulge Sign

• Patient standing/ Supine
• Knee extended
• Place your thumb and index finger on the medial and lateral parapatellar fossa
• Firmly compress the medial fossa ( to empty it)
• Sharply press lateral parapatellar fossa

The medial fossa will refill with a ripple

Patella Hollow Test

• Normally when the knee is gradually flexed
• Hollow appears and disappears just lateral to the patellar tendon
• In presence of intraarticular fluid when compared to opposite knee
• Refilling of Hollow occurs at a lesser angle

Patella Tap

• Knee extended
• Empty the suprapatellar bulge with the thumb and index finger
• Push fluid downward to the patella
• With the tip of the index and middle finger of your other hand
• Sharp tap the center of the patella
• So, that it sinks into an intercondylar groove in the femur
• Bounce up again

This test is ineffective when there is excessive fluid causing tight and tense swelling

Cross fluctuation

• Knee extended
• Place your thumb on one side and other fingers on another side of the suprapatellar bulge
• Other hands:- Place thumb and other fingers on the medial and lateral infrapatellar fossa
• Alternatively, squeeze the suprapatellar bulge and infrapatellar fossa to feel transmitted fluid impulse

Patellar Instability

Measure Q angle

• ASIS to the center of the patella- 1^st line
• Center of the patella to tibial tuberosity- 2^nd line

Dynamic Patellar tracking

Active Patellar tracking with the knee extended

Normally moves superiorly than laterally

If more lateral movement: Abnormal

Apprehension test

Knee in 20°-30° flexion

Manually subluxed patella laterally

Pain and resistance to lateral motion (Patient may suddenly get up)

Positive test

Test for Anterior Cruciate ligaments (ACL)

Anterior Drawer Test

• Patient Supine
• A hip flexed 45°, and Knee 90°
• Stabilize foot ( Sit on foot)

Ensure the tibia is not sagging behind otherwise false-positive result

Not Possible in Acute Painful Knee due to Hamstring Spasm and Door stopper effects of the medial meniscus

Details on Anterior Drawer test

Lachmann test

• Supine
• Knee flexed to 30°
• Slightly external rotation

Most sensitive test for ACL rupture

Useful in the painful knee and door stopper effect

Lelli’s Test

To identify a complete ACL tear

If patient’s heel remains on couch –> Fully torn ACL

Under-Sedation

Pivot Shift Test

Pre-requisites: Intact MCL

Gradual flexion of the extended internally rotated knee under valgus stress reduces the anteriorly subluxed lateral tibia at 30° flexion

Flexion for reduction of the lateral tibial condyle ( due to pulling of ITB)

• Supine/ relaxed
• Hip at 30° abduction
• Knee in IR and Valgus strain ( Subluxation of the knee)

Do gradual flexion from extension

• See for the reduction of the lateral femoral condyle
• Most specific for an ACL tear

Test for meniscus

Joint line tenderness

• Most sensitive test for meniscal injury
• Flex Hip and Knee to 90° and palpate for joint line tenderness

McMurray test

• Knee actively flexed forcefully
• Palpate the posterior margin of the knee joint
• Knee Externally rotated + Knee extension + Valgus force
• Click:- Suggestive of Medial Meniscus tear
• Palpate posterolateral margin
• Internally Rotated + knee extension + varus force (VARI)
• Click:- Suggestive of Lateral Meniscus tear

Negative Mcmurray does not rule out a tear

Apley’s Grinding test

Prone with Knee 90° flexion

Anterior thigh flexed against table foot and leg pulled upward/ downwards and rotated

Joint slowly flexed and extended

Pain/ Popping = Tear of meniscus

Thessaly Test

Stand in Injured leg with flexion 20° of knee

Hold arm for support

Rotate over tibia 3 times on each side

Pain present = Positive

Ege’s Test

(Weight-bearing Mcmurray test)

Not suitable patient in acute injuries

Standing position

Fully extended knee (14 cm apart)

Both legs marked external rotation

Squat and slowly stand Up

Both Knee in maximal internal rotation

Squat and stand Up

Pain present = Positive

Test for collaterals

Varus stress test

Feel for lateral joint line opening

Opening at 0°= LCL, Cruciate ligament tear

Opening at 30° = LCL tear

Valgus Stress test

Medial joint line opening

0° = MCL/ Cruciate

Opening at 30°= MCL tear

Test for PCL

Godfrey Sag Sign

Effect of gravity

The patient is kept in a Supine position

Flex Knee and Hip to 90°

Support heel

Tibia sag visibly posteriorly from the effect of gravity

Compare Silhouette on both sides

Quadriceps Active test

In doubtful PCL deficient knee

Contraction of quadriceps in a PCL deficient knee (90° of flexion)

Result in an anterior shift of the tibia by 2mm/ more

Ask patient to kick the leg in resistance by examiner’s hand

Posterior Drawer Test

• Supine position
• Knee flexed to 90°
• Sit on the foot of the patient
• Apply posterior direction force
• Excessive posterior laxity/no hard end felt suggestive of PCL tear

1^st thing is to reduce to knee in the neutral position

Dial test

External rotation of the tibia is done by holding in the ankle and twisting sideways compared to 30° and 90° flexion in prone/supine position

Asymmetry if > 10°

>10° increase external rotation -> Positive test

+ve at 30° knee flexion = Tear of the posterolateral corner (Isolated)

+ve at 30° + 90° knee flexion = Tear of posterolateral corner + tear of the posterior cruciate ligament

External Rotation Recurvatum test

• Supine Position
• Leg suspended from great toe by 10°
• See for 2 things:
  1. Leg fall in External Rotation (>10°)=> PCL tear is confirmed
  2. leg fall in Recurvatum=> Subluxation of tibia => ACL tear