by RYS

The Knee physical examination

Symptoms

• Pain– Diffuse– localized

• Swelling– Immediate– Some hours

• Stiffness• Locking• Deformity• Limp

SomebodyHelp my knee ??

knee

Observation

• Anterior view,standing

– Normally tibia has a slight valgus • Genu varum until about 18-19 months• Genu valgum until about 3-4 years

– Patella should symetrical and level• Squinting patella

– Deformity :• Valgus or knock knee

– Normal intermaleolar less than 6cm

• Varus or bowlegs– Normal intercondyler less than 8 cm

• Analyze gaitLook knee at– Heelstrike fully extended?– Swingphase flexion?

• Swelling– Intracapsuler ?

• generalized

– Extracapsuler ?• localized

• Lateral view, standing

– Genu recurvatum (hiperextended knee)– Patella displace

• High (alta)• Lower (baja)

• Posterior view, standing

– Similar to those in anterior– Baker’s cyst

• Anterior and lateral view, sitting

– Knee flexed 90 degree, feet dangling free– Patella face forward and on distal end femur– Displaced patella

• Frog’s eyes patella alta with lateral displaced

– Note tibial torsion• Medial associated with genu varum

– Pigeon toed foot deformity

• Lateral for genu valgum

Feel

• Warmth, intraarticular fluid

• Anterior– Quadriceps

• wasting

– Infrapatellar tendon• Insertion into tibial tubercle

– Prepatellar bursa• Housemaid knee

– Pes anserinus bursa

Prepatellar bursa

Superficial infrapatellar bursa

Deep infrapatellar bursa

Pes anserine bursa

• Medial– Medial meniscus

• Tenderness If detached due tears coronay ligament

– Medial collateral ligament• Move medially and posterior

– Sartorius,gracillis,and semitendinosus muscle• Position resistance against knee flexion

• Lateral– Lateral meniscus– Lateral collateral ligament– Common peroneal nerve

Lateral meniscus

Medial meniscus

• Posterior– Popliteal fossa– Posterior tibial nerve– Popliteal vein,artery– Gastrocnemius muscle

Move• Active

– Flexion (0°-135°)– Extension ( 0-15°)– Internal rotation (10°)– External rotation ( 10°)

Passive

Joint stability• Ligament

• Medial collateral ligament– Tes : abduction( VALGUS STRESS ) test

• Lateral collateral ligament– Tes : adduction ( VARUS STRESS ) test

Collateral ligaments

Anatomy

Posterior cruciatum ligamentAnterior cruciatum ligament

Medial collateral ligamentLateral collateral ligament

• Anterior cruciatum ligament– Knee flexed 90° hip 45 °

– Tes : ANTERIOR DRAWER TEST– Positive (+) there is forward movement tibia

• Posterior cruciatum ligaments– Tes : POSTERIOR DRAWER TEST– Positive (+) reverse anterior

• LACHMAN test– Knee flexed 20 degree– Positive(+) soft end feel forward tibia

slope (-)

Cruciatum ligaments

DRAWER TEST

LACHMAN test

Special test

• Meniscus injury– Mc Murray test

• Loose tag induced palpable and audible click

– Apley’s compresion distraction test• Grinding reproduces symptoms from meniscus torn• Distraction from ligament damage

Mc Murray test Apley’s test

Test for swelling

• Patellar tap test( ballotable patella )– Positive(+) Ballotement +

• Cross fluctuation test– Positive(+)Fluid impulse transmitted across the joint

• Bulge test– Positive(+) Distinct ripple seen

• Patellar hollow test– Normal : hollow +

Neurologic

• Muscle– Extension

• Primary extensor– Quadriceps ,femoral nerve L234

– Flexion• Primary flexor

– Hamstring » Semimembranosus, sciathic L5» Semitendinosus, sciathic L5» Biceps femoris, sciathic S1

• Sensation

L4L3L2S2

• Reflexes– Patellar reflexs, L234

Healthy Knee Joint ?May Be….

Terima Kasih

Ronny Sutanto

Uluwatu BeachUluwatu BeachSunset viewSunset view

BaliBali

Other special test

• Patellofemoral angle ( Q angle )– Angle between Q muscle and patellar tendon.– Normally 13° -18° – <13° patella alta or chondromalacia patella– >18° chondromalacia patella,sublux patella, genu

valgum,lateral tibial torsion.– If knee full extended normal 8-10°

• Apprehension test– For dislocation patella– Knee flexed 30°, slowly passive move patella

laterally– Positive if patient become apprehension

Observation

• Anterior view,standing

– Normally tibia has a slight valgus • Genu varum until about 18-19 months• Genu valgum until about 3-4 years

– Patella should symetrical and level• Squinting patella

– Deformity :• Valgus or knock knee

– Normal intermaleolar less than 6cm

• Varus or bowlegs– Normal intercondyler less than 8 cm

Tibiofemoral shaft angle normal 6º

Gravity Drawer test ( posterior sag sign )

Feel

Patient sit on the edge of examining tableknee flexed 90 degree relaxed,non weigthbearing.

• Medial aspect– Medial tibial plateau– Tibial tubercle– Medial femoral condyle– Adductor tubercle

• Lateral aspect– Lateral tibial plateau– Lateral tubercle

– Lateral tibial plateau– Lateral tubercle– Lateral femoral condyle– Lateral femoral epicondyle– Head of the fibula

• Trochlear groove and patella– Patella fixed in trochlear groove in flexion and mobile

in extension.

• Anterior and lateral view, sitting

– Excessive tibial torsion

-Chondromalacia patella

-Patellofemoral instability

-Fat pad entrapment

Osgood sclatter disease