Examination

The examination of the knee is divided into five phases: history, observation, inspection, palpation, and stress testing.

The current mechanism of injury as well as any prior serious injuries or surgical procedures frequently clarifies subtleties in the examination, allowing a more accurate diagnosis and appropriate treatment.

The patient should be examined while walking, if possible, and in both the sitting and lying positions. Take note of the gait, muscular development, functional range of motion, and the ability of the patient to extend the flexed knee against minimal resistance.

The knee should be inspected for swelling, ecchymoses, effusion, masses, patella location and size, muscle mass, erythema, and evidence of local trauma. With the patient supine, note whether leg lengths are equal or unequal. Lastly, ask the patient to perform the best possible active range of motion.

Initially the neurovascular status of the leg should be noted. As with all orthopedic examinations, the noninjured or normal knee should be compared with the injured knee during all aspects of the examination but especially during palpation and stress testing. When palpating the knee, begin in the nontender areas and work lastly toward the tender area so that the patient does not guard or become apprehensive. The patella and patellar facets, as well as the femoral and tibial condyles, should be palpated for pain and crepitance. Effusion, tenderness, increased temperature, strength, sensation, and location of pulses should be noted.

Examine the patella for size, shape, and location with the knee in flexion; check mobility with the knee in extension. The patella should be compressed to check for pain as well as moved laterally and medially to ascertain possible subluxation. The popliteal space should be palpated for masses, swelling, and pulses. Both the medial and lateral joint lines should be palpated because tenderness at those locations suggests the possibility of meniscal injury. Palpation of the medial and lateral collateral ligaments should also be performed with tenderness once again suggesting the possibility of injury.

The final phase of the examination of the knee is stress testing (also see section on Ligamentous and Meniscal Injuries). This is the most difficult aspect of the examination although potentially the most informative. The patient must be reassured and relaxed and made as comfortable as possible. This may require allowing the leg to hang over the side of the bed with the bed supporting the posterior thigh rather than the physician holding the leg, as is usually done during stress testing. The uninjured, hopefully normal, opposite knee should be examined first to determine the patient's normal laxity. A brief summary of the instabilities and tests to demonstrate them are presented in the section on ligamentous and meniscal injuries.

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