1. Palpate for tenderness: quads (also for defects and atrophy), quad tendon, infrapatellar tendon during active extension
2. "Extensor lag" = can't actively extend fully but full passive extension ok; suggests rupture or tear of extensor tendons--n.b. can have as little as a 20' extensor lag with a major extensor tear!
3. Check for recurvatum (hyperextension) on passive extension by holding pt's heels above level of table with pt. supine. Up to 20' is nl if bilat. Any unilat. recurvatum is abnormal (suggests ACL tear, especially if accompanied by noticeable extern. rotation of tibia)
4. Deficit of passive extension

1. if seems to be, check with pt prone and legs hanging off table
2. if due to mech. cause is called "locking;" if due to involuntary guarding due to pain is called "pseudolocking" Pts often have discoverer what maneuvers unlock their knee--ask!
3. Causes:

1. hamstring contracture
2. joint effusion
3. adhesions 2' to previous injury, e.g. of cruciates
4. meniscal tear--torn bit stuck between articular surfaces
5. patellar pain syndromes (causes pseudolocking)
6. if present, do "bounce test": With pt. supine hold heel in palm of hand above level of table; bounce it upward causing knee to flex and then abruptly jerk it upward, extending the knee. A normal knee will snap suddenly but painlessly into extension. A + bounce test is a soft stop--the knee slides softly into not-quite-full extension, often with pain. Suggests meniscal tear but can be other loose body in joint space sometimes seen with effusion.

1. Nl maximum flexion is about 150'
2. Test with pt supine; flex hip and knee simultaneously
3. Deficit of passive flexion 2' to either intrinsic or extrinsic probs, e.g. effusion, femur fx
4. Pain on complete flexion (passive) usually means pain is from patellofemoral articulation

1. Note size, shape, location, infectious signs, e.g. redness, heat (& whether focal)
2. Try to determine if they communicate with the joint space or not
3. Swelling right anterior to patella = prepatellar bursa
4. Diffuse swelling with loss of contours (e.g. hollows med & lat to patella) suggests fluid in joint space--see below for tests for this

1. Balottement of patella--milk suprapatellar bursa from prox==>dist, then place
2. 2 fingers on patella and press downward sharply, feeling for "tap" or patella on femur. If +tap, then +fluid in joint

1. Patella--most common source of all knee pain

1. Patellar source of pain divided into "patellar pain sd" (chondromalacia, patellofemoral OA) and "patellar instablility" (subluxation or dislocation)
2. Dx of patellar pain is supported by the following:

1. hx--no trauma, grad. onset, +chronic patellar use (knee bends)
2. worse on climbing & especially descending stairs
3. knee gets stiff when hasn't moved for a while
4. patellar tenderness
5. pain on rising from deep knee bend but none at bottom of bend
6. + "patellar compression test"--press on patella against femur, ouch!
7. - effusion
8. - McMurray's and Steinman's test (see below)

3. patellar pain may mimic menisceal tear, down to joint line tenderness!
4. pain usually felt to be medial or lateral rather than under the patella
5. palpate for tenderness: patella, retinaculum, quad & infrapat. tendons, tibial tubercule (Osgood-Schlatter's)
6. if patellae face outward, suggests instability or fem. neck anteversion
7. note "Q angle"--between quad and patellar tendons--should be 15-20'
8. check side-side mobility with knee extended; should be 2cm each way
9. if <, suggests patellofemoral OA or adhesions
10. if >, suggests instability
11. pain or apprehension on pt's face also suggest instability
12. crepitus on movement suggests patellofemoral OA
13. with pt. supine cross legs slightly and palpate deep surfaces for tenderness (suggests chondromalacia)
14. check "tracking" of patella on active extension--with dislocation, you see exaggeration of the normal lateral movement of the patella during terminal portion of extension

2. joint margin (between femoral condyles and tibial plateau)

1. best examined at 90' flexion;
2. for lateral joint line use "figure of 4" position, with knee flexed, femur ext. rotated, lat. ankle resting on opposite thigh
3. palpate for tenderness and swelling--go all the way back (posterior)!
4. firm, compressible swellings in a pt > 50 yrs are probably menisceal cysts which occur as part of degeneration of the meniscii
5. tenderness truly in the joint line probably represents a tear of either a meniscus or a coronary ligament (which hold the meniscii to thetibia laterally), but may also represent patellofemoral not-rightness

3. The collateral ligaments

1. palpate their points of attachment for tenderness; remember that LCL attaches to the fibula. Ligamental sprains usually present with well-localized pain and tenderness.
2. apply valgus/varus stress on knee and see if pt smacks you in head
3. should do it at 30' flexion because at full ext., ACL/PCL help support the knee against varus & valgus stresses
4. n.b. LCL tears very uncommon; when present us. also ACL or PCL tear

4. The meniscii

1. direct examination of the meniscii is, of course, impossible, but certain tests exist to check for meniscal injury
2. meniscal injury suggested by the following:
3. well-localized, intermittent pain, relieved by rest
4. injury involving twisting of body while on one foot or forced flexion, esp. with prevention of intern. tib rotation
5. c/o locking, with specific movements unlocking the joint
6. h/o prior ACL tear (with ACL gone meniscii help prevent
7. do deep knee bend--pain at a certain point, esp at nadir, suggests menisc.
8. tibial rotation
9. joint line tenderness
10. McMurray's test--pt. supine, knee fully flexed. Hold tibia once in external and once in internal rotation, each time slowly extending knee (to 90') while feeling lat. & med. joint line with thumb & forefinger of other hand for snaps/clicks; also check for pain. It's possible to confuse patellar clicks with clicks representing a torn flap of meniscus. If the latter occur with the internal rotation, it suggeststears of the posterior horn of the lat. menisc.; with external rot., it suggests tears of post. horn of med. meniscus.
11. Steinman's test--more specific for menisceal injury. Pt sitting, knee at 90' rotation, examiner just internally & externall rotates tibia, looking for same stuff as in McMurray's
12. Apley's test ("grind test")--just to mention it; it's complicated and not very useful

5. The cruciate ligaments

1. anterior drawer test (place anterior shearing force on tibia and see if it moves forward--nl is <5mm excursion; more suggests ACL tear) In addition to excusion, look for obliteration of usual sulcusbelow the patella, and feel for the "endpoint"--sudden jolt when ligament becomes taut and excursion ceases. Lack of endpoint is the most specific clinical test for ACL tear. n.b. with a PCL tear can get a false + anterior drawer test because the initial position of the tibia is recessed and you're pulling it into normal anatomic position. Checking for the endpoint avoids this pitfall.
2. Lachman's test--an anterior drawer test with the knee in 30' flexion instead of 90' flexion--more sensitive
3. posterior drawer test (place posterior shearing force on tibia--analagous to anterior; tests for PCL tear)
4. pivot shift test--pt. supine, 30' flexion; apply valgus strain and slowly extend knee; a shift suggests ACL damage
5. reverse pivot shift test

6. Other areas

1. bursae--prepatellar (housemaid's), infrapatellar (Madonna's), semimembranosus (just inf. to the posteriomedial joint line--this is common), pes anserinus (a conjoint tendon of 3 hamstring muscles; the bursa is on med. side of the knee, inferior to joint line), iliotibial tract bursa (at lateral femoral condyle)
2. popliteus tendon--insertion is at lat. fem. condyle; sprain is suggested by tenderness here, pain worse with internal tibial rotation, and pain running downhill)
3. synovial reflection--on femoral condyles. Check for thickening
4. pop. fossa--pt in prone position; check for swellings
5. Baker's cyst (most common)--projection of synovial sheath
6. Popliteal aneurysm--auscultate any pop. fossa mass for bruits!
7. synovial sarcoma (rare entity, but a common place for it to present)