Orthopaedic examination of any bone or joint follow the same basic structure:

LOOK - gait (if lower limb), erythema, swelling, scars, deformity, muscle wasting

FEEL - warmth, tenderness, swelling, crepitus

MOVE - range of motion, power

SPECIAL TESTS - joint stability, isolated muscle power, provocative tests

JOINT ABOVE & BELOW - ensure pain not radiating from elsewhere

NEUROVASCULAR - examine neurological and vascular supply to limb

This is followed by INVESTIGATIONS - blood tests, X-rays, further imaging

Each section describes a basic technique to examine the joints regularly seen in the exams and clinics. By following the routine described above, most joints can be examined thoroughly. The text does not provide an exhaustive description of every test available but outlines the commonly used basic examinations.

Knee examination

LOOK 

Gait - Antalgic (short stance phase due to pain)

Scars - midline longitudinal (total knee replacement, ACL reconstruction with patella tendon), arthroscopy portals (anteromedial and anterolateral), posterior (PCL surgery or vascular surgery)

Muscle wasting - Quadriceps wastes after acute knee injury. Mark a point 10cm above tibial tuberosity (fixed bony point), measure circumference of thigh, compare to contralateral side

Erythema - infected pre-patellar bursitis presents with gross erythema over front of knee

Swelling - large effusion within knee joint may be visible. Pre-patellar bursitis has large fluctuant swelling over front of patella

Deformity - VaLgus (lower leg deviates Laterally), Varus (lower leg deviates medially), fixed flexion

Lie patient supine on examination couch.

FEEL 

Warmth - inflammation or infection will lead to a warm joint – use dorsum of hand to feel the knee

Effusion - slide hand down over supra-patella pouch, milking fluid into knee joint and hold firmly above patella, “ballot” patella into tibia with large effusion (patella tap test), stroke fluid from medial side of knee to lateral side (bulge test) for smaller effusion

Tenderness - medial or lateral joint line tenderness (easier to palpate with knee flexed to 90°). Tenderness with pressure upon patella into trochlea (patella grind test) indicates patellofemoral disease

Crepitus - noted with hand over patella with range of motion tests - indicates possible patellofemoral disease

MOVE 

Range

1.             Extension-flexion 0-130°

Straight leg raise - extensor apparatus (quadriceps tendon, patella, patella tendon, tibial tubercle) intact

SPECIAL 

Anterior drawer - knee flexed 90°, foot planted on bed and stablised. Examiner grasps patient’s tibia, fingers around calf, thumbs on tibial tubercle and tugs tibia forward - anterior displacement implies ACL laxity

Lachman’s test - knee flexed 30°, examiner grasps and stabilises thigh with left hand. Right hand grasps tibia, with thumb on tibial tubercle, and tugs tibia forward - anterior displacement implies ACL laxity

Posterior sag - both knees flexed to 90°, side by side. PCL deficient knee will have a posterior sag of tibia compared to contralateral side, showing an abnormal contour along line drawn from distal tip of patella through tibial tubercle and anterior border of tibia

Posterior drawer - knee flexed 90°, foot planted on bed with examiner sitting on it. Examiner grasps patient’s tibia, fingers around calf, thumbs on tibial tubercle and pushes tibia backwards - posterior displacement implies PCL laxity

Valgus stress test - grasping shin and foot under right arm and using left hand to stabilise thigh, valgus stress applied to knee - opening of joint implies medial collateral ligament laxity

Varus stress test - grasping shin and foot under right arm and using left hand to stabilise thigh, varus stress applied to knee - opening of joint implies lateral collateral ligament laxity

McMurray’s test - knee flexed with one hand to 90° whilst the sole of the foot is grasped with the other hand. The foot is internally rotated whilst knee is extended - medial joint pain or a click indicates a medial meniscal tear. The foot is then externally rotated whilst knee is extended - lateral joint pain or a click indicates a lateral meniscal tear

Hip examination - hip pain may radiate to the knee - isolate the hip and ensure movement does not mimic the patient’s symptoms, indicating a hip-related cause of the pain