Examination sequence

□ With the patient standing, note the presence of genu valgum or genu varum.

□ If genu valgum is present, measure the distance between the medial malleoli with the patient standing and knees just touching. In genu varum, measure the gap between the medial condyles of the femur with the feet together.

□ With the patient supine, inspect the limb alignment and note any deformity, bony contour, loss of muscle bulk (especially quadriceps), erythema or swelling. A large effusion may be observed as a horseshoe swelling above the patella.

□ If quadriceps wasting is present, record and compare muscle girth at a selected level above the patella (say 10 cm) in both thighs.

□ With the knee flexed, palpate the joint line to elicit tenderness. Also note any tenderness above or below the joint line which may denote collateral ligament pathology.

□ Note the presence of synovial swelling including any synovial distension in the popliteal fossa (Baker's cyst).

Testing for an effusion

'The patellar tap'

□ With the knee extended, apply pressure with one hand to empty any fluid within the suprapatellar pouch into (he retropatellar space. If there is sufficient fluid this will lift the patella off the underlying femoral condyle.

□ With the fingers of the opposite hand, press down on the patella and fluctuation may be noticed. If this is repeated with a more brisk downward pressure on the patella, a tapping sensation may be felt as the patella hits the femur (Fig. 8.3 I). If the effusion is very tense the tap is difficult to elicit.

Patellar Tap Test

'The massage lest' - to elicit a small effusion

□ With the knee straight and the quadriceps relaxed, stroke any fluid on the medial side of the joint up and across into the lateral aspect of the suprapatellar pouch (Fig. 8.32A).

□ Then, without delay, firmly stroke down the lateral side of the knee in an attempt to push any fluid back onto the medial side of the knee. If fluid is present, a fluid impulse will be seen to cause a transient bulge on the anteromedia! side of the knee (Fig. 8.32B).

Movement

□ With patient supine, note the presence of any flexion deformity of the knee. If the knee is flexed this may he due to pathology in knee, hip or both.

□ Test whether full passive extension of the knee is possible, or whether it is a fixed incorrectable flexion deformity (contracture).

□ Check for 'extensor lag', which indicates quadriceps weakness. Ask the patient to lift the leg while attempting to keep the knee as straight as possible. If the patient cannot keep the knee fully extended, an 'extensor lag' is present.

□ Measure the range of active flexion using a goniometer (normal range 0-140 degrees). If there is a flexion deformity of say 15 degrees and the knee can be flexed to 1 10 degrees, the range of movement would be recorded as 15-110 degrees. At Ihe limit of active flexion, check the range of passive flexion.

□ When indicated, as in a suspected cartilage lesion, assess any minor limitation of full extension which may not be visible wilh the palient supine. Turn the patient into the prone position with the thigh supported on the

Suprapatellar Pouch Massage

Fig. 8,32 Testing for an effusion in the right knee by the massage test.

H Massage any fluid away from the medial side ol the knee. 13 Apply firm downward pressure over the lateral side of the knee and observe for fluid displacement.

Fig. 8,32 Testing for an effusion in the right knee by the massage test.

H Massage any fluid away from the medial side ol the knee. 13 Apply firm downward pressure over the lateral side of the knee and observe for fluid displacement.

Fig. 8.33 Flexion contracture in presence of cartilage lesion.

Fig. 8.33 Flexion contracture in presence of cartilage lesion.

bed and the lower leg projecting over the end of the examination couch. Observe the relative level of the heels. In the presence of a flexion deformity one heel will remain higher than the other (Fig. 8.33).

□ When indicated, perform tests for instability, as described below.

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