Knee Examination Long Case Template

1. Introduction and Preparation

• Wash hands, introduce yourself, confirm patient identity.
• Explain: “I would like to examine both of your knees, including walking, looking, feeling, and moving the joints. Some movements may cause discomfort, so please tell me if they do.”
• Obtain consent.
• Ask about pain and offer analgesia if needed.
• Expose both lower limbs from mid-thigh to feet. Compare both sides throughout.
• Ensure the patient is initially standing, then walking, then lying supine on the couch.

2. General Inspection

General observation

• Patient comfortable or distressed?
• Walking aids, knee brace, footwear, orthoses?
• Body habitus, fever, skin rash, evidence of systemic disease?
• Scars elsewhere suggesting prior surgery?

Gait

• Antalgic gait
• Stiff-knee gait
• Varus or valgus thrust
• Inability to fully extend knee
• Difficulty weight-bearing
• Use of walking aid

Standing alignment

• Varus deformity: genu varum
• Valgus deformity: genu valgum
• Fixed flexion deformity
• Hyperextension: genu recurvatum
• Tibial torsion, foot deformity
• Pelvic tilt or limb-length discrepancy

3. Local Inspection

Look for

• Swelling or effusion, especially suprapatellar fullness
• Erythema or bruising
• Scars: arthroscopy portals, arthrotomy, total knee replacement scar
• Sinus or discharge
• Skin changes: psoriasis, tophi, venous changes
• Muscle wasting, particularly quadriceps wasting
• Bony swelling or joint-line prominence
• Patellar position:
  • Patella alta or baja
  • Lateral displacement
  • Squinting patellae
• Popliteal swelling, suggesting Baker cyst

4. Palpation

Temperature

• Increased warmth may suggest active inflammation, infection, or crystal arthritis.

Effusion

• Bulge or swipe test for small effusion
• Patellar tap / ballottement for moderate effusion
• Cross-fluctuation for large effusion

Bony landmarks and soft tissues

• Quadriceps tendon
• Superior pole of patella
• Patella
• Patellar tendon
• Tibial tuberosity
• Infrapatellar fat pad

• Medial patellar facet
• Medial joint line
• Medial collateral ligament
• Pes anserinus bursa, around 4 to 5 cm below medial joint line

• Lateral patellar facet
• Lateral joint line
• Lateral collateral ligament
• Iliotibial band and Gerdy tubercle
• Head of fibula
• Common peroneal nerve posterior to fibular neck

• Popliteal fossa for fullness, tenderness, pulsatility
• Baker cyst if suspected

• Site of maximal tenderness
• Crepitus
• Bony enlargement
• Synovial thickening
• Localized swelling or mass

5. Movement

Flexion

• Ask patient to bend knee as far as possible.
• Normal flexion is approximately 135 degrees.
• Note pain, restriction, crepitus, or inability to flex.

Extension

• Ask patient to fully straighten knee.
• Normal extension is 0 degrees.
• Identify:
  • Fixed flexion deformity
  • Extensor lag
  • Hyperextension

Patellofemoral movement

• Feel for crepitus during flexion and extension.
• Observe patellar tracking.
• Assess medial and lateral patellar glide if appropriate.

Hip examination

6. Functional Assessment

• Sit and stand from a chair
• Squat partially
• Step up or down
• Perform a single-leg squat
• Walk on heels and toes

• Pain
• Instability
• Weakness
• Patellar maltracking
• Quadriceps weakness
• Dynamic valgus

7. Ligament Assessment

Anterior cruciate ligament

• Knee flexed about 20 to 30 degrees.
• Stabilize femur and pull tibia anteriorly.
• Positive: increased anterior translation or soft endpoint.

• Knee flexed to 90 degrees.
• Pull tibia anteriorly.
• Positive: increased anterior translation.

• Usually performed by experienced examiners.
• Suggests ACL insufficiency when positive.

Posterior cruciate ligament

• Hip and knee flexed to 90 degrees.
• Observe posterior sag of tibia.

• Push tibia posteriorly.
• Positive: excessive posterior translation.

Medial collateral ligament

• Test at 0 degrees and 30 degrees flexion.
• Pain or laxity suggests MCL injury.
• Laxity in full extension may indicate additional capsular or cruciate injury.

Lateral collateral ligament

• Test at 0 degrees and 30 degrees flexion.
• Pain or laxity suggests LCL injury.

8. Meniscal Assessment

Joint-line tenderness

• Medial or lateral joint-line tenderness may indicate meniscal pathology, but is not diagnostic alone.

McMurray test

• Flex knee fully.
• Rotate tibia while extending knee:
  • External rotation stresses medial meniscus.
  • Internal rotation stresses lateral meniscus.
• Positive: joint-line pain, palpable click, or locking.

Thessaly test

• Patient stands on one leg with knee flexed about 20 degrees, then rotates body.
• Positive: joint-line pain, clicking, or locking.
• Do not perform if acute pain, instability, or poor balance.

9. Patellofemoral Assessment

Patellar apprehension test

• With knee slightly flexed, glide patella laterally.
• Positive: apprehension or quadriceps contraction suggests patellar instability.

Patellar grind test

• Apply gentle pressure to patella while patient contracts quadriceps.
• Pain may suggest patellofemoral pathology, but this test has limited specificity and should not be used in isolation.

Clarke test

• Sometimes used for patellofemoral pain, but may be uncomfortable and is not routinely necessary.

10. Neurovascular Examination

Pulses

• Popliteal pulse
• Dorsalis pedis pulse
• Posterior tibial pulse

Sensation

• Common peroneal nerve distribution: dorsum of foot and first web space
• Tibial nerve distribution: sole of foot
• Saphenous nerve distribution: medial leg and foot

Motor function

• Ankle dorsiflexion: deep peroneal nerve
• Great-toe extension: deep peroneal nerve
• Ankle plantarflexion: tibial nerve
• Foot eversion: superficial peroneal nerve

Suggested Long Case Presentation

“I examined both lower limbs, focusing on the knees. The patient had a [normal/antalgic/stiff] gait with [or without] a walking aid.

On standing, there was [varus/valgus/fixed flexion/no] deformity. The affected knee showed [effusion/scar/quadriceps wasting/erythema/bony enlargement], with no evidence of [sinus or skin lesion].

On palpation, the joint was [warm/not warm], with tenderness localized to the [medial joint line/lateral joint line/patellar tendon/pes anserinus]. There was [no/small/moderate/large] effusion, demonstrated by [bulge sign/patellar tap].

Movement was restricted in [flexion/extension/both], with a range from ___ to ___ degrees. There was [crepitus/pain/extensor lag].

Ligament testing showed [stable ligaments / positive Lachman / valgus laxity / varus laxity]. Meniscal testing was [negative/positive] for [medial/lateral] meniscal pathology. Patellar examination demonstrated [normal tracking/apprehension/crepitus]. Neurovascular examination was intact.

Overall, these findings are most consistent with ________. My differentials include ________. I would complete the examination by assessing the hip, examining other joints where appropriate, and reviewing gait, imaging, and relevant systemic features.”

Findings-to-Diagnosis Quick Guide

Red flags

• Fever, a hot swollen joint, severe pain, or systemic illness: consider septic arthritis.
• Inability to bear weight after trauma.
• Acute deformity, absent distal pulses, or neurological deficit: consider knee dislocation or vascular injury.
• Locked knee: possible displaced meniscal tear or loose body.

10-Minute OSCE Station: Examination of the Knee

Candidate Instructions

Examine this patient’s knee(s).
You do not need to take a history.
Tell the examiner what further examination you would perform at the end.

Equipment

• Examination couch
• Stool
• Tape measure, optional
• Tendon hammer, optional
• Goniometer, optional

Time-Based OSCE Sequence

0:00-1:00: Introduction, Consent, Exposure

Say

“Hello, I am ___, one of the medical students/doctors. Could I confirm your name and date of birth?”

“I have been asked to examine your knees. This will involve looking, feeling, and moving both knees, as well as asking you to walk. Some parts may be uncomfortable, so please tell me if you feel pain and I will stop. Is that okay?”

• Wash or sanitize hands.
• Ask: “Do you have pain in either knee at the moment?”
• Offer analgesia or modify examination if needed.
• Expose both legs from mid-thigh to feet.
• Compare both sides throughout.

Examiner points

• Introduces self and confirms identity
• Explains procedure and gains consent
• Checks pain
• Adequate exposure
• Uses contralateral comparison

1:00-2:00: Gait and Standing Inspection

Look for

• Antalgic gait
• Stiff-knee gait
• Limp
• Varus thrust or valgus thrust
• Use of walking aid
• Ability to weight bear
• Difficulty turning

Inspect standing alignment

• Genu varum
• Genu valgum
• Fixed flexion deformity
• Genu recurvatum
• Limb-length discrepancy
• Foot posture and tibial torsion

Say

“Could you walk to the end of the room, turn around, and walk back at your usual pace?”

2:00-3:30: Supine Inspection

Look from the end of the bed, front, side, and posteriorly

• Swelling, especially suprapatellar fullness
• Effusion
• Erythema
• Bruising
• Scars: arthroscopy portals, arthrotomy, knee replacement
• Sinus or discharge
• Skin lesions, psoriasis, tophi
• Quadriceps wasting
• Bony enlargement
• Patellar position or maltracking
• Popliteal swelling, if visible

Key OSCE phrase

“I would inspect both knees for asymmetry, scars, erythema, swelling, effusion, muscle wasting, deformity, and skin changes, including the popliteal fossae.”

3:30-5:30: Palpation and Effusion

Temperature

“I am checking the temperature around both knees.”

Effusion tests

1. Bulge / swipe test for small effusion
   • Milk fluid from medial side upward into suprapatellar pouch.
   • Sweep down lateral gutter.
   • Look for medial bulge.
2. Patellar tap / ballottement for moderate effusion
   • Compress suprapatellar pouch.
   • Push patella posteriorly.
   • Positive if patella taps the femur.
3. Cross-fluctuation for large effusion
   • Compress one side of the joint and feel fluid impulse on the other.

Palpate in a consistent order

• Quadriceps tendon
• Superior pole of patella
• Patella and patellar facets
• Patellar tendon
• Tibial tuberosity

• Medial joint line
• Medial collateral ligament
• Pes anserinus region

• Lateral joint line
• Lateral collateral ligament
• Iliotibial band
• Head of fibula
• Common peroneal nerve around neck of fibula

• Popliteal fossa for fullness or tenderness

During palpation assess

• Tenderness
• Warmth
• Crepitus
• Synovial thickening
• Bony enlargement
• Masses

5:30-6:45: Movement and Extensor Mechanism

Active movements

“Could you bend your knee as far as possible?”
“Now straighten it fully.”

• Flexion, normally to about 135 degrees
• Extension, normally to 0 degrees
• Painful arc
• Crepitus
• Fixed flexion deformity
• Hyperextension

Passive movements

• Gently assess flexion and extension.
• Compare sides.
• Feel for crepitus at patellofemoral joint.

Extensor mechanism

“Can you lift your straight leg off the bed and hold it there?”

6:45-8:45: Special Tests

Ligament tests

ACL

• Knee 20 to 30 degrees flexed.
• Stabilize femur and pull tibia forwards.
• Assess anterior translation and endpoint.

• Knee flexed to 90 degrees.
• Pull tibia anteriorly.

PCL

• Hips and knees flexed to 90 degrees.
• Look for posterior sag of tibia.

• Push tibia posteriorly.

MCL

• At 30 degrees flexion, then in extension.
• Assess pain and medial joint opening.

LCL

• At 30 degrees flexion, then in extension.
• Assess pain and lateral joint opening.

Meniscal tests

Joint-line tenderness

• Palpate medial and lateral joint lines.

McMurray test

• Flex knee, rotate tibia, and extend:
  • External rotation tests medial meniscus.
  • Internal rotation tests lateral meniscus.
• Positive finding: pain, click, or locking.

Thessaly test

• Patient stands on one leg with knee flexed approximately 20 degrees.
• Rotates body internally and externally.
• Positive: joint-line pain, click, or locking.

Patellofemoral tests

Patellar apprehension

• Gently move patella laterally with knee slightly flexed.
• Positive: apprehension or quadriceps contraction.

Patellar tracking

• Observe patella while patient actively flexes and extends knee.
• Note lateral tracking or J-sign.

8:45-9:30: Function and Neurovascular Assessment

Function

• Squat or partial squat
• Sit to stand
• Step up or down, if available

Neurovascular assessment

• Popliteal, dorsalis pedis, and posterior tibial pulses
• Sensation over:
  • First dorsal web space: deep peroneal nerve
  • Dorsum of foot: superficial peroneal nerve
  • Sole: tibial nerve
• Ankle dorsiflexion and great-toe extension: common/deep peroneal nerve function

9:30-10:00: Close and Present Findings

Close

“Thank you, that completes my examination. You can relax and cover yourself.”

State completion

“To complete my examination, I would examine the hip and ankle joints, assess the contralateral knee, perform a full neurovascular examination, and examine other joints and relevant systems if inflammatory or systemic disease is suspected.”

Example presentation

“On examination, the patient has a [varus/valgus/fixed flexion/no] deformity of the ___ knee. There is [an effusion/no effusion], [warmth/no warmth], and tenderness over the ___. Knee movement is from ___ to ___ degrees, with [pain/crepitus/no crepitus]. The extensor mechanism is intact. Ligament testing demonstrates ___. Meniscal tests are ___. Distal neurovascular status is intact.

These findings are most consistent with ___. My differential diagnoses include ___.”

10-Minute OSCE Checklist

Essential marks

• Introduction, consent, hand hygiene, pain check
• Exposes both knees adequately
• Observes gait
• Assesses standing alignment
• Inspects both knees systematically
• Checks temperature
• Assesses for effusion
• Palpates joint line, patella, tendons, collateral ligaments, fibular head, and popliteal fossa
• Assesses active and passive flexion and extension
• Tests extensor mechanism
• Performs relevant ligament testing
• Assesses menisci and patellofemoral joint where appropriate
• Assesses distal neurovascular status
• Summarizes findings
• States examination of hip, ankle, contralateral knee, and other joints to complete assessment

If Time Is Short: Minimum Safe Sequence