1. By inspection and palpation, note position and mobility of patellae. Knee extension-flexion range is 0 to 130 degrees. Also palpate for the presence of osteophytes at tibiofemoral joint margin, which may also be tender.
2. Soft-tissue swelling is elicited by bimanual examination.
a. Demonstrate intraarticular fluid by the patellar click sign. While compressing the suprapatellar pouch with one hand, push the patella against underlying fluid and the femoral condyle with the index finger of the other hand to elicit a click.
b. For detection of a small amount of effusion, use the bulge sign. This maneuver is best executed by placing both hands on the knee so that the index fingers meet on the medial joint margin and the thumbs meet on the lateral aspect of the joint. Through a firm stroking motion of the fingers above and below the patella, fluid is "milked" into the interior of the joint, and the medial aspect of the joint becomes flat. The thumbs are then pushed suddenly and firmly into the lateral joint margin, thus producing a bulge of fluid on the medial side of the joint.
3. The popliteal area is examined for the presence of a synovial cyst. Standing makes the cyst more prominent.
4. Knee stability is evaluated by stressing medial and lateral collateral ligaments. Anteroposterior stability is assessed by holding the knee flexed with the foot firmly anchored on the bed and using both hands to pull and push the leg (drawer sign) to test the cruciate ligaments.
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