Knee Exam

Aka: Knee Exam, Knee Examination, Knee Joint Finding, Knee Maneuver

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II. Exam: Telemedicine

  1. See Telemedicine
  2. Both knees should be exposed (e.g. shorts)
  3. Evaluate patients gait from front and side (see standing exam below)
  4. Perform knee general exam as below (observation, self-palpated tenderness and range of motion)
  5. Perform specific knee tests as able (see below)
  6. Consider Knee XRay or other imaging indications
    1. Ottawa Knee Rule (if Knee Pain after Trauma)
    2. Inability to actively extend the knee (e.g. Patella injury, quadriceps Tendon Injury)

III. Exam: General (compare with less affected knee)

  1. Observation
    1. Obvious injury findings
      1. Deformity
      2. Ecchymosis
    2. Overlying skin changes
      1. Erythema
      2. Open wound (e.g. Open Joint Injury, Open Fracture)
      3. Skin Tenting
      4. Previous surgical scars
    3. Knee Effusion or swelling with obscured landmarks
      1. See Knee Effusion
      2. See Knee Effusion Causes
      3. See Ballottable Patella Sign
      4. See Knee Bulge Sign
    4. Quadriceps Muscle atrophy
      1. Evaluate Vastus Medialis Obliquus specifically
      2. Atrophy often on side of Ligamentous Injury
  2. Tenderness to Palpation
    1. Anterior (see Patella below)
      1. Patella (Fracture, Contusion, Prepatellar Bursitis)
      2. Tibial tubercle (avulsion Fracture, Patellofemoral Syndrome, Osgood-Schlatter)
      3. Patellar tendon (Patellar Tendonitis, Sinding-Larsen-Johansson Syndrome)
      4. Quadriceps tendon (e.g. Quadriceps Tendonitis)
    2. Medial
      1. Medial Meniscus Tear (joint line tenderness)
      2. Osteoarthritis
      3. Medial plica (tender Nodule at joint line)
      4. Pes Anserine Bursitis (3 cm inferior to anteromedial joint line)
      5. Medial collateral ligament tear
      6. Medial Tibial Plateau Fracture
      7. Osteochondral or subchondral insufficiency Fracture
    3. Lateral
      1. Iliotibial Band Syndrome (proximal tibial tenderness at IT Band insertion, Gerdy Tubercle)
      2. Lateral Meniscal Tear
      3. Lateral collateral ligament tear
      4. Lateral Tibial Plateau Fracture
      5. Osteochondral or subchondral insufficiency Fracture
      6. Proximal fibular Fracture (e.g. Maisonneuve Fracture)
    4. Posterior
      1. Popliteal Cyst (Baker's Cyst)
      2. Gastrocnemius Tear (typically medial gastrocnemius tendon)
      3. Posterior Cruciate Ligament Tear
      4. Tear of posterior aspect of meniscus
      5. Hamstring injury or tenderness
        1. Semimembranosus Tendonitis (posteromedial)
        2. Semitendinosus Tendonitis (posterolateral)
  3. Knee Range of Motion
    1. Note knee resting position
    2. Normal range of motion
      1. Flexion: 135 degrees
      2. Extension: 0 to -10 degrees (above horizontal plane)
        1. Significant effusion or Monoarthritis may limit knee extension to <25 degrees from a resting flexed position

IV. Exam: Patella

  1. Patella deformity or focal tenderness
    1. Patella Fracture or Contusion
  2. Quadriceps tendon insertion tenderness
  3. Patellar tendon insertion tenderness (inferior pole Patella)
    1. Patellar Tendonitis (Jumper's Knee)
    2. Sinding-Larsen-Johansson Syndrome (early teens)
  4. Tenderness to the medial or lateral aspect of the Patellar tendon (but not immediately over the tendon)
    1. Infrapatellar fat pad (Hoffa's fat pad)
  5. Tibial Tuberosity Tenderness
    1. Osgood-Schlatter Disease (teens)
    2. Patellofemoral Syndrome
    3. Tibial tubercle avulsion (with Trauma History)
  6. Patellofemoral Syndrome
    1. Quadriceps Femoris Muscle Angle (Q Angle)
    2. Patella tracking with quadriceps contraction
      1. Evaluate for smoothness of motion and crepitation
    3. Patellar Apprehension Test
      1. Evaluates for Patella Subluxation and Patellar instability

V. Exam: Ligaments

  1. Anterior Cruciate Ligament (ACL) Stability Tests in ACL Tear
    1. Lever Test (most sensitive)
    2. Lachman Test (second most sensitive)
    3. Knee Anterior Drawer Test
    4. Pivot Shift Test (MacIntosh Test)
  2. Posterior Cruciate Ligament (PCL) Tests in PCL Tear
    1. Knee Posterior Drawer Test
    2. PCL Sulcus Test
    3. PCL Sag Test
  3. Collateral ligament evaluation
    1. Knee Valgus Stress Test (Medial collateral ligament tear)
    2. Knee Varus Stress Test (Lateral collateral ligament tear)

VI. Exam: Meniscus

  1. See Meniscus Injury
  2. McMurray's Test
  3. Apley's Compression Test and Apley's Distraction Test
  4. Knee Bounce Test
  5. Thessaly Test
  6. Inability to fully extend knee may suggest "bucket-handle" meniscal tear
  7. Joint line tenderness is 76% sensitive for meniscal tear, but not specific

VII. Exam: Neurovascular

  1. See Sensory Exam
  2. Lower extremity Motor Exam
    1. See Motor Exam
    2. Femoral Nerve (L1-L4)
      1. Hip flexion against resistance (Iliopsoas Muscle)
    3. Sciatic Nerve (L5-S2)
      1. Knee flexion against resistance (Hamstring Muscles)
    4. Deep Peroneal Nerve (L4-L5): Foot Drop
      1. Dorsiflexion against resistance (tibialis anterior Muscle)
    5. Tibial Nerve (S1-S2)
      1. Plantar flexion against resistance (gastrocnemius Muscle, soleus Muscle)
  3. Deep Tendon Reflexes
    1. Patellar Reflex (L2-4)
    2. Achilles Reflex (S1)
  4. Distal pulses
    1. Dorsalis Pedis Pulse
    2. Posterior Tibial Pulse
  5. Miscellaneous
    1. Compartment Syndrome findings (significant limb circumferential swelling, pain out of proportion)

VIII. Exam: Standing Evaluation

  1. Inability to bear weight is a red flag for more significant injury or illness (e.g. Fracture, Acute Monoarthritis)
  2. Balanced weight on each leg
  3. Deformity
    1. Genu Varum
      1. orthoKneeGenuVarum.jpg
    2. Genu Valgum
      1. orthoKneeGenuValgum.jpg
  4. Gait analysis
  5. Patella baja or Patella alta deformity
  6. Hip, Knee, and ankle alignment

IX. Imaging

  1. See Knee Imaging
  2. See Knee XRay
  3. See Knee XRay Indications in Acute Injury (e.g. Ottawa Knee Rules)
  4. See Knee Ultrasound

X. References

  1. Bach (1997) Physician Sportsmed, 25(5): 39-50
  2. Budoff (1997, April) Consultant, 919-30
  3. Budoff (1997, Feb) Consultant, 295-304
  4. Hoppenfeld (1976) Physical Exam, Prentice-Hall
  5. Bunt (2018) Am Fam Physician 98(9): 576-85 [PubMed]
  6. Calmbach (2003) Am Fam Physician 68(5):907-12 [PubMed]
  7. Pendergraph (2026) Am Fam Physician 114(1): 49-62 [PubMed]
  8. Rothenberg (1993) Postgrad Med, 93(3): 75-86 [PubMed]
  9. Smith (1995) Am Fam Physician 51(3):615-21 [PubMed]
  10. Solomon (2001) JAMA 286:1610-20 [PubMed]
  11. Yedlinsky (2021) Am Fam Physician 103(3):147-54 [PubMed]

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