Special Issues (region-specific history checks)
- Have back or leg pain? (is dermatomal pain – knee pain can be mentioned from the back)
- Have hip or ankle pain? (Knee pain can be from the hip or affected by the biomechanics of the ankle)
- Does the patient hear pops/clicks when injured?
- Will the knee come loose? (ligament instability/rupture)
- Are the knees locked? (true meniscus lock associated with torn barrel handle)
- Is your knee swollen? too fast? Where is the swelling? (Intra-articular/extra-articular; immediate swelling usually indicates trauma within the knee, such as ligament damage)
- Are there any bruises? (Immediate bruising indicates severe trauma
- Cough/sneeze cause pain?
- Age – The following conditions are not unique to these age groups, but are more prevalent in these populations (older – OA? young – osgoods schlatters middle age – meniscus).
- Type of shoe (wearing pattern/age of shoe/appropriate design)
Additional Information
- Past Medical History (PMH) (Past Medical History)
- Drug History (DH) (Any related drugs?)
- Social History (SH) (work/sports/hobbies affected?
Investigations
- Radiology Notes – Any previous X-rays or scans
- Other investigations – any recent blood test
Red Flags
These are special issues that may indicate that something more sinister may be going on. If you suspect that the problem is not a musculoskeletal problem and/or a potentially sinister problem, you should immediately refer the patient to their doctor and note your concerns.
- LL Acupuncture or numbness bilaterally.
- Problems with bowel and bladder function, the patient cannot feel himself going to the toilet.
- Incontinence.
- Paraesthesia in the groin region.
- LL Pulse loss (vascular damage).
- Obvious deformity.
If nothing ominous, but symptoms are more severe than you expected, ask older adults if emergency referrals are more appropriate. The mechanism of injury is important here. What force is exerted through the leg? Are tibia/femur fractures enough? foot pulse loss possible Indicates blood vessel damage.
Clinical Reasoning - What Does History Tell You?
Make sure to exclude the back and hips, unless there is a clear mechanism of injury, as the knee can be the site of pain in these two areas. Immediate swelling and bruising usually indicates severe trauma and may require X-rays to rule out tibial plateau fractures, bone contusions, or MRI Investigate ligament integrity.
Enter your objective inspection with a working hypothesis. Use your physical exam to identify dysfunction and special tests to prove or disprove your hypothesis.
Objective
Objective examination gives you quantifiable measures to rule out which structures are involved and reassess after treatment to determine improvement/worsening.
General Observation
- Posture
- Movement Patterns
functional Tests
- Small knee bend
- Sit to stand
- Squat
- Jump
- Hop
- Run
Inspection & Palpation
Inspection
- Effusion
- Poor Alignment
- Muscle Wasting
Palpation
- MCL
- LCL
- Joint Line
- Patella
- Retinaculae
- Patellar Tendon
- Hamstrings Tendons
- Popliteus.
Neurologic Assessment
If a neurological deficit is suspected or a lumbar spine referral is suspected, you should have a neurological evaluation:
Reflexes
- Patella Ligament (L3/L4)
- Achilles Tendon (S1/S2)
Dermatomes
- L1 to S4
Myotomes
- L2 Hip Flexion
- L3 Knee Extension
- L4 Dorsiflexion
- L5 big toe stretch or 4 little toe stretch
- L5/S1 Knee Flexion
- S1 Plantar flexion or foot eversion
- S2 Toe Flexion
Other neurological tests include: Babinski and clonus
Movement Testing
- AROM, PROM, and Overpressure
- Muscle Strength and length
- Full AROM + Overpressure Clears Hip and Ankle
- If the lumbar spine is suspected, increase passive intervertebral motion (PA Spinous Process PA Transverse Process).
Special Tests
Special tests are used to prove or disprove your working hypothesis and identify dysfunctional structures. View the full list of special knee tests
ACL
- Lachman’s Test
- Anterior drawer
- Pivot-Shift
- Slocum’s Test
PCL
- Sag sign
- Posterior Drawer
MCL/LCL
- Valgus stress test
LCL
- Varus stress tests
- Dial Test (postero-lateral corner)
Meniscus
- McMurrays
- Bounce home
- Joint line tenderness
- Apley’s Test
- Ege’s Test
- Steinman Test
- Thessaly test
Patellofemoral
- Apprehension
- Grind Test (Clarkes sign)
ITB
- Noble’s compression
- Ober’s Test
Osteochondritis Dissecans
- Wilson’s Test
Assessment and Management of common knee injuries
References
- BJSM video. Knee Exam (1 of 27): Introduction. Available at: http://www.youtube.com/watch?v=MpWVqi6C9RY [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (2 out of 27): Exam: Standing. Available at: http://www.youtube.com/watch?v=MpWVqi6C9RY [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (3 of 27): Walking. Available at: http://www.youtube.com/watch?v=8FToHsom980 [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (4 of 27): Balance. Available at: http://www.youtube.com/watch?v=PO7e-h8h2FU [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (9 of 27): Exam and Palpation: Supine. Available at: http://www.youtube.com/watch?v=ONA_y0znCoU [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (5 of 27): Neurovascular Assessment: Supine. Available at: http://www.youtube.com/watch?v=xeW7dwcBZCI [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (6 of 27): Hip Exam: Supine. Available at: http://www.youtube.com/watch?v=wFB9WxfPFWI [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (7 of 27): Range of Motion Part 1. Available at: http://www.youtube.com/watch?v=z33P1xBpBt0 [Last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (8 of 27): Range of Motion Part 2. Available at: http://www.youtube.com/watch?v=9c4ePN7hOdE[Last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (10 of 27): Effusion. Available at: http://www.youtube.com/watch?v=5DxTb2_r8lk [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (11 of 27): Effusion (minor). Available at: http://www.youtube.com/watch?v=ViMiwp5w-yE [last accessed 25/01/14]
- ↑ BJSM video. Examination of the knee joint (12 of 27): Lachman test. Available at: http://www.youtube.com/watch?v=dH_jnTy1rNk [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (13 of 27): Posterior Drawer. Available at: http://www.youtube.com/watch?v=rP_1cZgMEq0 [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (14 of 27): MCL. Available at: http://www.youtube.com/watch?v=NMi2RsAohSw [last accessed 25/01/14]
- ↑ BJSM video. Knee examination (15 of 27): LCL. Available at: http://www.youtube.com/watch?v=GDheZioSCs4 [last accessed 25/01/14]
- ↑ BJSM video. Examination of the knee joint (16 of 27): posterolateral corner. Available at: http://www.youtube.com/watch?v=bnXaTdvZZ6o [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (17 of 27): Meniscus Assessment: Palpation and Bounce Home Test. Available at: http://www.youtube.com/watch?v=52reQsXQAZk [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (18 of 27): McMurray’s Test. Available at: http://www.youtube.com/watch?v=fkt1TOn1UfI [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (19 of 27): Apley’s Test. Available at: http://www.youtube.com/watch?v=GDheZioSCs4 [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (20 of 27): Acute Patellofemoral Injury. Available at: http://www.youtube.com/watch?v=BDJXSYlMK4k [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (21 of 27): Standing McMurray’s Test. Available at: http://www.youtube.com/watch?v=FGs1WlmUdWg [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (22 of 27): Pivot Displacement. Available at: http://www.youtube.com/watch?v=ZWEGB0ToXZo [Last Accessed 25/01/14]
- ↑ BJSM video. Knee Exam (23 of 27): ACL Evaluation Part 1. Available at: http://www.youtube.com/watch?v=hXU-TbyNZmg [last accessed 25/01/14]
- ↑ BJSM video. Knee Exam (24 of 27): ACL Assessment Part 2. Available at: http://www.youtube.com/watch?v=3h7wZle9FcY [last accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (25 of 27): ACL Assessment Part 3 (Ms. Rahman). Available at: http://www.youtube.com/watch?v=MJgfajhsnCM [Last Accessed 25/01/14]|}
- ↑ BJSM video. Examination of the knee joint (26 of 27): Examination of ACL cases. Available at: http://www.youtube.com/watch?v=44-Of-664DU [Last Accessed 25/01/14]|}
- ↑ BJSM video. Knee Exam (27 of 27): Pearls & Pitfalls. Available at: http://www.youtube.com/watch?v=ysj5rIAcaA0 [last accessed 25/01/14]|}
- ↑ Wilson L and Blaney A. Physical therapy management of common knee disorders in primary care settings. Irish Association of Chartered Physiotherapists. [Accessed 26 January 2015]
