Knee joint is an important jpoint for movement and transmitting body weight to the ground. It is very frequent for this joint to get affected by problems. A careful history should highlight the chronology of the knee complaint. A probable list of of causes should be explored in history. Any predisposing condition like trauma, or medications that might underlie the complaint should be asked.
History is followed by observation of the patient’s gait.
The knee should be carefully inspected in the upright (weight-bearing) and prone positions for
- Swelling
- Erythema
- Contusion
- Laceration
- Malalignment.
The most common form of malalignment in the knee is genu varum (bow legs) and genu valgum (knock knees).
Bony swelling of the knee joint commonly results from hypertrophic osseous changes seen with disorders such as osteoarthritis and neuropathic arthropathy.
Swelling caused by hypertrophy of intrasynovial structures (synovial enlargement or effusion) may manifest as a fluctuant, ballotable, or soft tissue enlargement in the suprapatellar pouch or lateral and medial to the patella downward towards the femoral groove or by balloting the patella downward toward the femoral groove or by eliciting a bulge sign.
To elicit this sign, the examiner positions the knee extended and manually compresses or milks synovial fluid down from the suprapatellar pouch and lateral to the patellae. Manual pressure lateral to the patella may cause an observable shift in synovial fluid (bulge) to the medial aspect.
This maneuver is only effective for detecting small to moderate effusions (smaller than 100 mL).
Inflammatory disorders such as RA, gout and Reiter’s syndrome may involve the knee joint and produce significant pain, stiffness, swelling, or warmth.
Anserine bursitis is an often missed cause of knee pain in adults. The pes anserine bursa underlies the semimembranosus tendon and may become inflamed and painful owing to trauma, overuse, or inferior and medial to the patella and overlying the medial tibial plateau. Swelling and erythema may not be present. Other forms of bursitis may also present as knee pain.
The prepatellar bursa is superficial and is located over the inferior portion of the patella. The infrapatellar bursa is deeper and lies beneath the patellar ligament before its insertion on the tibial tubercle.
Internal derangement of the knee may result from trauma or degenerative processes. Damage to the meniscal cartilage frequently presents as chronic or intermittent knee pain. Such an injury should be suspected when there is a history of trauma or athletic activity and when the patient relates symptoms of locking, clicking, or “giving way” of the joint.
Pain may be detected during direct palpation over the medial or lateral joint line. The diagnosis may also be suggested by ipsilateral joint line pain when the knee is stressed laterally or medially.
A positive McMurray test may indicate a meniscal tear.
Mcmurray Test
The knee is first flexed at 90 degree, and the leg is then extended while simultaneously the lower extremity is torqued medially or laterally. A painful click during inward rotation may indicate a lateral meniscus tear, and pain during outward rotation may indicate a tear in the medical meniscus.
Damage to the cruciate ligaments should be suspected if there is pain of acute onset, possibly with swelling, a history of trauma, or a synovial fluid aspirate that is grossly bloody. Examination of the cruciate ligaments is best accomplished by eliciting a drawer sign.
Drawer Sign
With the patient recumbent, the knee should be partially flexed and the foot stabilized on the examining surface. The examiner should manually attempt to displace the tibia anteriorly or posteriorly with respect to the femur. If anterior movement is detected, then anterior cruciate ligament damage is likely. Conversely, significant posterior movement may indicate posterior cruciate damage. Contralateral comparison will assist the examiner in detecting significant anterior or posterior movement.
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