Complete Musculoskeletal Exam of the Knee

This video shows a complete knee exam. View the complete knee examination learning module at https://sites.google.com/a/umich.edu/fammed-modules/

Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition.

CC: BY-NC University of Michigan Family Medicine Residency Program. This material is licensed under a Creative Commons Attribution - Noncommercial 3.0 License http://creativecommons.org/licenses/by-nc/3.0/.

(English captions by Andrea Matsumoto from the University of Michigan)

To ensure a thorough assessment it is best
to preform the musculoskeletal exam of the

knee in a systematic way.

The following is a suggested order of exam
that incorporates many of the common techniques

used for evaluating knee injuries.

Begin the exam with the patient in the standing
position.

Look for evidence of gross deformity, muscular
atrophy, symmetry of the patellar alignment,

evidence of varus or valgus positioning of
the knee, or presence of pes planus or pes

cavus of the foot.

From a posterior view observe for more than
two toes laterally, also called the "too

many toes" sign.

This can indicate an over-pronated foot or
an abducted forefoot.

Have the patient perform a toe raise and evaluate
the heel position.

Normally the heel should change from a neutral
to a varus position.

Next observe the gait looking for an antalgic
gait or excessive pronation or supination.

Next evaluate active range of motion.

If pain or limitation exists repeat the range
of motion passively.

In a seated position test for knee extension.

In this position also observe patellar tracking.

And, internal and external rotation of the
hip which can help identify referred knee

pain caused by hip pathology.

Also in the seated position, palpate anatomic
landmarks for tenderness.

Palpate the distal quadriceps, quadriceps
tendon, the patella, patellar tendon, the

tibial tuberosity, and the fat pads beneath
the patella.

On the medial side palpate the medial collateral
ligament, the medial joint line, the pes anserine

bursa.

On the lateral side, the lateral collateral
ligament, the lateral joint line, and the

fibular head.

Posteriorly palpate the popliteal fossa and
the distal hamstrings.

With the patient supine the leg can be fully
extended to assess better for joint diffusion.

Compress the suprapatellar pouch, pushing
the contents distally, and assess for increased

fluid.

Patellar ballottement can also be performed
by compressing the patella and releasing quickly.

Observe for rapid rebound, which also indicated
increased fluid pressure.

If a click or tap is felt a large effusion
is present, also called the ballottable patella.

The patellar grind test assesses for patella-femoral
syndrome.

With the knee extended push the patella into
the trochlear groove of the femur.

Pain is a positive test.

The patellar inhibition test assess for patella-femoral
syndrome also.

With the knee extended, push the superior
aspect of the patella inferiorly as the patient

tightens the quadriceps muscle.

Pain or crepitus is considered a positive
test.

The patellar apprehension test evaluates for
patellar subluxation of dislocation.

With the knee extended push medially and laterally
on the patella in an attempt to sublux the

patella.

If it is painful or the patient becomes apprehensive
about the movement it is a positive test.

There are several tests commonly performed
to evaluate for ligamentous laxity of the

knee.

Medial collateral ligament stability can be
tested at zero degrees and thirty degrees

of flexion by applying a valgus force on the
knee.

Lateral collateral ligament stability can
also be tested at zero degrees and thirty

degrees of flexion by applying a varus force
to the knee.

Laxity indicates a partial or complete ligamentous
tear.

The Lachman�s test evaluates for a tear
of the anterior cruciate ligament.

With the knee flexed to thirty degrees, stabilize
the femur and pull the proximal tibia anteriorly.

Excessive motion or soft endpoint is a positive
test.

The anterior drawer test assesses of a tear
of the anterior cruciate ligament also.

With the knee flexed to ninety degrees and
the foot planted on the table, push the proximal

tibia anteriorly.

Excessive motion or soft endpoint is a positive
test.

The posterior drawer test assesses for a tear
of the posterior cruciate ligament.

With the knee flexed at ninety degrees and
the foot planted on the table, push the proximal

tibia posteriorly.

Excessive motion or a soft endpoint is a positive
test.

The PCL sag test evaluates for a tear of the
posterior cruciate ligament.

With both knees flexed to ninety degrees and
feet planted on the table, view the knees

from the side to compare the position of the
tibia.

Increased posterior sag of one of the tibias
is considered a positive test.

The McMurray�s test evaluates for a miniscule
tear.

With the patient supine and knee fully flexed,
palpate the medial joint line and apply an

axial force along the tibia while externally
rotating and extending the knee.

This maneuver is repeated palpating the lateral
joint line while internally rotating the foot.

Pain, catching, or palpable clunk indicates
a miniscule tear.

The bounce test also evaluates for a miniscule
tear.

Grasp the heel, extend, and bounce the leg,
gently forcing hyperextension.

Pain is a positive test.

In the prone position, Apley�s compression
test evaluates for a miniscule tear.

Flex the knee to ninety degrees, apply an
axial force along the tibia, and rotate the

tibia.

Pain is a positive test.

Ober�s test assesses for iliotibial band
syndrome.

With the patient in the lateral position,
the knee is supported and flexed to ninety

degrees.

Then extend and abduct the hip and release
the knee support.

Failure of the knee to adduct is a positive
test.

In the seated position, Noble�s test can
also be used to evaluate for iliotibial band

syndrome.

With the knee flexed to ninety degrees, apply
pressure over the lateral femoral chondral

and passively extend the knee.

Lateral pain around thirty degrees of flexion
is a positive test.

In concluding the knee exam, it's important
to document a neurovascular exam.

Here we demonstrate dorsalis pedis artery
pulse, posterior tibial artery pulse, and

capillary refill testing.

A more thorough exam may be indicated based
on patient history.