How to document knee examination in orthopedic

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knee examination documentation orthopedic clinical format

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Documenting the Knee Examination in Orthopedics

A well-documented knee examination follows a systematic Look - Feel - Move - Special Tests framework, always comparing both knees side by side.

1. History (Subjective)

Document the following before the physical exam:

Chief complaint: Pain, swelling, instability, locking, giving way
Mechanism of injury: Contact vs. non-contact; position of the knee at time of injury (weight-bearing, flexion/rotation); direction of force (valgus, varus, hyperextension, dashboard)
Onset: Acute (traumatic) vs. gradual/insidious
Symptom details: Immediate swelling (suggests hemarthrosis - ACL/fracture) vs. delayed swelling (suggests meniscal injury); audible or felt "pop"; locking (inability to fully extend - meniscal tear or loose body)
Functional limitations: Walking distance, stairs, squatting, sporting activity
Previous knee history: Prior injuries, surgeries, injections, physiotherapy; contralateral knee status
Risk factors: Age, BMI, activity level, sport, alignment

"Locking of the knee joint means the joint can be flexed freely but cannot be extended beyond a certain degree." - S Das Manual on Clinical Surgery

2. Inspection (Look)

Document with the patient standing first, then supine.

Standing - Inspect from Front, Side, and Back

Finding	What to Document
Alignment	Varus (bow-legs - measure intermaleolar distance) or valgus (knock-knees - measure intermalleolar gap); recurvatum (hyperextension)
Gait	Antalgic gait (pain-avoidance, shortened stance phase); varus thrust (knee collapses into varus during weight-bearing - suggests lateral compartment OA); Trendelenburg
Scars	Previous surgical scars (arthroscopy ports, total knee replacement - describe location and healing)
Swelling	Horseshoe-shaped swelling around the patella = effusion; swelling in the popliteal fossa = Baker's cyst
Quadriceps wasting	Measure thigh circumference with a tape measure at 10-15 cm above the patella, compare bilaterally
Skin	Bruising/ecchymosis, redness, psoriatic plaques, gouty tophi
Patellar position	Alta (high-riding patella) or baja (low-riding); lateral tilt

Document example:

"Right knee: mild effusion with horseshoe-shaped suprapatellar swelling. Valgus alignment. Quadriceps wasting noted - thigh circumference 38 cm right vs. 42 cm left at 15 cm above patella. No scars."

3. Palpation (Feel)

Perform with the patient supine, knee slightly flexed (~30°).

a) Temperature

Compare both knees with the back of your hand
Warmth suggests inflammation or infection

b) Effusion Tests - Document which test used and result

Test	Technique	Documents
Fluid displacement / Stroke test	Stroke fluid from medial gutter up into suprapatellar pouch, compress pouch, watch for cross-filling into medial gutter	Small to moderate effusion
Patellar tap test	Empty suprapatellar pouch with one hand; push patella sharply down with other - feel for a tap/bounce	Large effusion

c) Bony Palpation - Document tenderness location precisely

Patella (facets, inferior and superior poles)
Tibial tuberosity (Osgood-Schlatter in adolescents)
Medial and lateral joint line (meniscal tears)
Medial collateral ligament - femoral origin vs. joint line vs. tibial insertion
Lateral collateral ligament
Quadriceps tendon and patellar tendon (palpable defect = rupture)
Popliteal fossa (Baker's cyst, posterior capsule)
Fibular head (LCL/PLC injury)

Point-of-tenderness documentation (from Das):

Femoral attachment of MCL → MCL sprain
Joint line, medial side → medial meniscus injury
Midway between patellar tendon and MCL at joint line → anterior horn meniscus tear
Posterior to MCL → posterior horn meniscus tear
Both sides of ligamentum patellae → fat pad impingement

Document example:

"Medial joint line tenderness +++. No lateral joint line tenderness. No patellar facet tenderness. Moderate effusion - positive patellar tap. Patellar and quadriceps tendons intact. No popliteal swelling."

4. Movement (Move)

Document active and passive range of motion (ROM) with a goniometer when possible.

Movement	Normal Range	Document
Flexion	0-135°	Achieved angle; pain at end of range
Extension	0° (full) to -10° (hyperextension)	Lack of full extension = fixed flexion deformity (FFD)
Hyperextension	Up to -10°	Degree of recurvatum

Key Tests to Document Under Movement

Extensor lag test: Ask patient to SLR (straight leg raise) at 10°, then bend and re-extend. Inability to re-extend = extensor mechanism failure (quadriceps/patellar tendon rupture, or patellar fracture). Document: positive/negative.
Fixed flexion deformity (FFD): If apparent FFD seen, sit patient with knees over couch edge to eliminate hip flexion contribution. Document degrees of FFD.

Document example:

"ROM right knee: flexion 0-110° (limited by pain), lacks full extension - FFD 10°. Extensor lag test negative. Left knee: full ROM 0-135°."

5. Special Tests

Group and document by structure being tested.

a) Collateral Ligaments

Test	Technique	Documents
Valgus stress (MCL)	Apply valgus force at 0° and 30° knee flexion	Positive = medial gapping; Grade I/II/III
Varus stress (LCL)	Apply varus force at 0° and 30°	Positive = lateral gapping

"Testing at 30° isolates the collateral ligament; laxity at 0° also implies posterior capsule/cruciate involvement." - Bailey & Love

Document: Side, degree of laxity (trace/1+/2+/3+), pain, end-point (firm vs. soft)

b) Cruciate Ligaments

Test	Technique	Documents
Lachman test	Knee at 30° flexion; stabilize femur, translate tibia anteriorly	ACL integrity; graded by millimeters of displacement and end-point quality
Anterior drawer	Hip at 45°, knee at 90°; draw tibia forward	ACL (less sensitive than Lachman)
Posterior sag sign (Godfrey)	Hips and knees at 90°; tibia sags posteriorly under gravity	PCL tear
Posterior drawer	Knee at 90°; push tibia posteriorly	PCL
Quadriceps active test	With knee at 90°, patient contracts quads; anterior shift = PCL tear	PCL
Pivot shift test	Valgus + internal rotation stress with knee extending	ACL rotatory instability

Document example:

"Lachman test: positive right, grade 2 with soft endpoint. Anterior drawer: positive. Posterior drawer: negative. Posterior sag: absent. Pivot shift: positive (clunk) right."

c) Menisci

Test	Technique	Documents
McMurray's test	Flex knee fully, externally rotate foot then extend (medial); internally rotate then extend (lateral)	Click or pain at joint line = positive
Thessaly test	Weight-bearing, knee at 20°, rotate body; medial/lateral joint line pain	Positive = pain on rotation
Apley's grind test	Prone, knee at 90°; compress and rotate	Positive = pain reproduced

Document example:

"McMurray positive for medial meniscus (click at 90° with ER). Lateral McMurray negative."

d) Patellofemoral Joint

Test	Technique	Documents
Patellar apprehension test	Gently displace patella laterally; patient guards = positive	Patellar instability/dislocation
Clarke's test / Patellar grind	Compress patella inferiorly, patient contracts quads	Pain = chondromalacia patellae
Q-angle measurement	ASIS to mid-patella to tibial tuberosity	Normal: <15° male, <20° female; increased = patellar maltracking

e) Posterolateral Corner (PLC)

Dial test: At 30° and 90° knee flexion, externally rotate both feet. Asymmetric ER >10° at 30° only = isolated PLC injury; at both 30° and 90° = combined PLC + PCL.

6. Neurovascular Assessment

Always document - especially after trauma:

Distal pulses: Dorsalis pedis (DP) and posterior tibial (PT) pulses
Capillary refill time
Sensation: Distribution of saphenous, common peroneal, tibial nerves
Motor: Ankle dorsiflexion (deep peroneal), plantarflexion (tibial)

7. Documentation Template (SOAP Format)

ORTHOPEDIC KNEE EXAMINATION NOTE

Date:          Side: Right / Left / Bilateral     Visit type: New / Follow-up

SUBJECTIVE:
Chief complaint:
Mechanism:
Duration / Onset:
Symptoms: Pain (VAS __/10, location), swelling, instability, locking, giving way
Functional status:
Prior treatment:

OBJECTIVE:

Inspection (standing):
  Alignment: Neutral / Varus / Valgus
  Gait: Normal / Antalgic / Varus thrust
  Swelling: None / Mild / Moderate / Large
  Quadriceps wasting: None / Thigh circ. R__ cm vs. L__ cm (at 15 cm above patella)
  Scars/skin:

Palpation:
  Temperature: Normal / Warm
  Effusion: None / Small / Moderate / Large (stroke test / patellar tap)
  Joint line tenderness: Medial / Lateral / None
  Ligament tenderness: MCL / LCL / AT MCL insertion / midsubstance
  Patellar tenderness: None / Facets / Inferior pole / Superior pole
  Popliteal fossa:

Range of Motion:
  Flexion: Active __ ° / Passive __ °
  Extension: Full / FFD of __ °
  Extensor lag: Positive / Negative

Special Tests:
  Lachman: Positive / Negative (grade __, endpoint: firm/soft)
  Anterior drawer: Positive / Negative
  Posterior drawer: Positive / Negative
  Posterior sag sign: Positive / Negative
  Pivot shift: Positive / Negative
  Valgus stress (0°/30°): Stable / Lax __ mm
  Varus stress (0°/30°): Stable / Lax __ mm
  McMurray: Medial Positive / Negative; Lateral Positive / Negative
  Patellar apprehension: Positive / Negative
  Dial test (30°/90°): __ ° ER asymmetry

Neurovascular:
  DP pulse: Present / Absent   PT pulse: Present / Absent
  Sensation: Intact / Deficit at:
  Motor: Normal / Deficit:

Imaging:
  X-ray: [findings]
  MRI: [if obtained]

ASSESSMENT:
  Diagnosis / Differential:

PLAN:
  Conservative / Operative / Investigations

Summary of Key Documented Findings by Diagnosis

Diagnosis	History	Examination	Special Test
ACL tear	Non-contact, pivot, "pop," immediate swelling	Hemarthrosis	Lachman +, Pivot shift +
PCL tear	Dashboard injury, posterior pain	Posterior sag	Posterior drawer +
MCL tear	Blow to lateral knee, medial pain	Medial laxity at 30°	Valgus stress +
Medial meniscus	Rotation injury, delayed swelling, locking	Medial joint line tenderness	McMurray +
Patellar dislocation	Lateral swelling, anterior pain	MPFL tenderness	Apprehension +
OA	Chronic, insidious, activity-related	Crepitus, bony enlargement, FFD	N/A

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition (pp. 512-513)
S Das: A Manual on Clinical Surgery, 13th Edition (pp. 207-209)
Rosen's Emergency Medicine: Concepts and Clinical Practice (Box 48.1)
Orthobullets: History and Physical Exam of the Knee
Geeky Medics: Knee Examination OSCE Guide

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