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Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions

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Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions Review Article Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions Abstract Robert D. Bronstein, MD The knee is one of the most commonly injured joints in the body. Its Joseph C. Schaffer, MD superficial anatomy enables diagnosis of the injury through a thorough history and physical examination. Examination techniques for the knee described decades ago are still useful, as are more recently developed tests. Proper use of these techniques requires understanding of the anatomy and biomechanical principles of the knee as well as the pathophysiology of the injuries, including tears to the menisci and extensor mechanism, patellofemoral conditions, and osteochondritis dissecans. Nevertheless, the clinical validity and accuracy of the diagnostic tests vary. Advanced imaging studies may be useful adjuncts. ecause of its location and func- We have previously described the Btion, the knee is one of the most ligamentous examination.1 frequently injured joints in the body. Diagnosis of an injury General Examination requires a thorough knowledge of the anatomy and biomechanics of When a patient reports a knee injury, the joint. Many of the tests cur- the clinician should first obtain a rently used to help diagnose the good history. The location of the pain injured structures of the knee and any mechanical symptoms were developed before the avail- should be elicited, along with the ability of advanced imaging. How- mechanism of injury. From these From the Division of Sports Medicine, ever, several of these examinations descriptions, the structures that may Department of Orthopaedics, are as accurate or, in some cases, University of Rochester School of have been stressed or compressed can Medicine and Dentistry, Rochester, more accurate than state-of-the-art be determined and a differential NY. imaging studies. diagnosis can be formulated. Pre- To evaluate knee pathology, Neither of the following authors nor vious injuries should also be sought any immediate family member has familiarity with examination tech- because the current injury may be the received anything of value from or has niques for the menisci, extensor sequela of a prior insult. stock or stock options held in a mechanism, patellofemoral condi- commercial company or institution As with any physical examination, related directly or indirectly to the tions, and osteochondritis dissecans an orderly routine is of great impor- subject of this article: Dr. Bronstein (OCD) and with the associated tance. When the knee is evaluated, the and Dr. Schaffer. anatomy and biomechanics is essen- sequence should involve inspection, J Am Acad Orthop Surg 2017;25: tial. Methods that increase diagnostic assessment of active and passive 365-374 sensitivity and accuracy should be range of motion (ROM), palpation, DOI: 10.5435/JAAOS-D-15-00464 incorporated. Advanced imaging, and special tests, with any potentially such as MRI, can then be used as uncomfortable tests performed last. Copyright 2017 by the American Academy of Orthopaedic Surgeons. necessary but should not replace the To ensure a thorough examination, history and physical examination. both of the patient’s lower extremities May 2017, Vol 25, No 5 365 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions Figure 1 musculature, particularly the quad- the area of discomfort and examining riceps, should be inspected for atro- the area of reported pain last. A sug- phy. In addition, the patella should be gested approach is to begin anteriorly assessed for malalignment, which and work posteriorly, starting with may predispose the patient to mal- the quadriceps tendon and then pal- tracking or patellar dislocation. pating the patella, patellar tendon, Patella alta or baja is generally as- and tibial tuberosity. Next, the medial sessed with the patient in the seated and lateral patellar facets can be pal- position and can be confirmed pated while assessing for the appre- radiographically. hension sign. Then the medial and Any localized swelling and masses, lateral joint lines should be palpated Clinical photograph demonstrating including swelling of the prepatellar and the remainder of the examination knee effusion by “milking” the fluid bursa, a meniscal cyst, and Osgood- performed, including specific tests for from the suprapatellar pouch with one hand. The other hand palpates Schlatter disease of the tibial tubercle, ligaments and menisci. As noted pre- the so-called balloon of fluid. should be noted. A popliteal (ie, viously, any test that is expected to Baker) cyst can be palpated posteri- cause pain should be done last. orly with the knee extended. Swelling Finally, it is important to remember should be fully exposed. An of the distal femur or proximal tibia that pain felt in the knee may be assessmentofgaitshouldbeper- may indicate a neoplasm or infection. referred from other locations, including formed first, looking for varus or The knee should be inspected for a the spine and the hip. A careful history valgus, quadriceps avoidance, and prepatellar or intra-articular effu- can help differentiate referred spinal antalgic gaits. Substantial primary sion. An effusion of the prepatellar pain. Routine examination of the hip varus or valgus deformity may be bursa is anterior to the patella; with and spine is recommended when eval- the result of single-compartment an intra-articular effusion, the patella uating knee pain, with particular osteoarthritis. With quadriceps remains palpable subcutaneously. attention paid to loss of hip rotation. avoidance, the patient bears weight On inspection, a true knee joint with a knee locked in extension effusion is often best appreciated in because of either a weakened the suprapatellar pouch. The effusion The Menisci extensor mechanism or pain. An can be “milked” from the supra- antalgic gait can result from any patellar pouch with one hand, while The medial and lateral menisci are condition causing knee pain. the other hand palpates the effusion crescent-shaped cartilaginous struc- Next, an assessment of standing (Figure 1). tures, triangular in cross-section, that limb alignment should be performed, Next, ROM should be assessed, serve important biomechanical func- taking note of specifics, such as pes first with active motion and then with tions in the knee. These include load planus and excessive femoral ante- gentle passive motion if necessary. bearing, shock absorption, joint sta- version, both of which can contribute Compared with the contralateral bility and congruity, joint lubrication, to patellofemoral tracking problems. knee, the injured knee may fail to and proprioception. As early as 1803, Excessive femoral anteversion may reach full passive extension, which Hey2 recognized injury to the menis- be identified by an inward-pointing may indicate a mechanical block or cus as a cause for locking of the knee. or so-called squinting patella. hamstring spasm. Limited ROM is The biology, anatomy, development, The patient should then be posi- expected with large knee effusions or and degeneration of the meniscus tioned supine on an examination pain. Although full ROM is required were described by McMurray.3 The table. The uninjured knee should be for a complete knee examination, it is injury mechanism is typically a twist- examined first. This relaxes the not always possible at the first visit ing moment through the knee in the patient and helps to reassure him or and should not be forced. A short flexed, weight-bearing position.4 Pain her that the examination will not course of physical therapy with re- experienced at the time of injury is cause pain, while also accounting for examination in several days to 1 week variable, followed by the insidious individual variations between the can be helpful. onset of an effusion over the next day. uninjured knee and the contralateral Tenderness on palpation combined Patients may experience mechanical knee. We have found that telling the with knowledge of knee anatomy is symptoms, such as catching, locking, patient to relax his or her hip as well especially useful for diagnosis. Pal- clicking, or instability, and usually as the knee facilitates passive motion pation should be done systematically, report either medial or lateral knee and instability examinations. The altering the approach depending on pain. 366 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Robert D. Bronstein, MD, and Joseph C. Schaffer, MD Figure 2 A, Clinical photograph showing the lateral McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is internally rotated (white arrow), engaging the posterior horn of the lateral meniscus under the lateral femoral condyle. The knee is then extended (black arrow), entrapping the meniscus. B, Clinical photograph showing the medial McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is externally rotated (white arrow), engaging the posterior horn of the medial meniscus under the medial femoral condyle. The knee is then extended (black arrow), entrapping the meniscus. The lateral and medial menisci dif- With the patient supine, the knee is Of note, McMurray3 did not men- fer somewhat in anatomy. The lateral fully flexed, and the examiner tion varus or valgus stress. Some meniscus is more circular
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