How to document knee examination in orthopedic
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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
What if i have done knee aspiration 25 ml. How to document that
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knee aspiration arthrocentesis procedure note documentation orthopedic synovial fluid
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https://www.ncbi.nlm.nih.gov/books/NBK537114
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Documenting a Knee Aspiration (Arthrocentesis) - 25 mL Aspirated
When you perform a knee aspiration, you need two separate documentation entries: a Procedure Note and an update to your Examination/Progress Note. Here is exactly how to write each.
Part 1: The Procedure Note
A procedure note is a standalone entry documenting what you did, how, and what resulted. It covers 8 essential elements:
Template - Knee Aspiration Procedure Note
PROCEDURE NOTE - KNEE ARTHROCENTESIS
Date/Time:
Operator:
Supervisor (if applicable):
1. INDICATION
Right/Left knee effusion - [state reason: traumatic hemarthrosis /
suspected septic arthritis / inflammatory arthritis / pain relief /
diagnostic workup of acute monoarthritis]
2. CONSENT
Risks, benefits, and alternatives explained to patient.
Written / Verbal consent obtained. Patient agreed to proceed.
3. PATIENT POSITION
Supine, knee in slight flexion (approx. 20°) supported by rolled towel
under the popliteal fossa.
4. SITE PREPARATION
Right / Left knee. Superolateral approach (1 cm lateral and superior
to the patella).
Skin cleaned with chlorhexidine / betadine / alcohol swab in sterile
fashion. Sterile draping applied.
5. ANESTHESIA
Local anesthesia: 2 mL of 1% lidocaine without epinephrine infiltrated
subcutaneously at insertion site.
[OR: No local anesthetic used / Topical ethyl chloride spray used]
6. TECHNIQUE
Under sterile conditions, an 18-gauge needle attached to a 20 mL syringe
was inserted 1 cm superolateral to the patella, directed 45° downward
and posteriorly under the patella. A distinct "pop" was felt on entry
into the joint space. Free flow of fluid was obtained immediately.
Gentle milking of the suprapatellar pouch was performed to maximize
drainage.
7. FLUID OBTAINED
Volume aspirated: 25 mL
Appearance: [Straw-yellow / clear / turbid / bloody / serosanguineous /
frank blood / fat globules visible]
Viscosity: [Normal / Reduced / Watery]
[e.g. "25 mL of straw-yellow, slightly turbid fluid aspirated."]
8. SAMPLES SENT
□ Cell count and differential (EDTA tube)
□ Gram stain and culture (sterile container)
□ Crystal analysis - polarized microscopy (plain tube)
□ Glucose / LDH / protein (if indicated)
[State which were sent and why]
9. POST-PROCEDURE
Needle removed. Pressure applied. Sterile dressing applied.
No immediate complications.
Neurovascular status post-procedure: DP and PT pulses intact,
sensation normal, capillary refill < 2 seconds.
Patient tolerated procedure well.
10. FOLLOW-UP PLAN
Fluid results to be reviewed within 24-48 hours.
[If corticosteroid injected: e.g. "40 mg triamcinolone injected
intra-articularly after aspiration."]
Patient advised to rest, avoid strenuous activity for 24 hours.
Return if fever, increased pain, or swelling.
Part 2: Update Your Progress/Examination Note
In the main SOAP note, update the Objective and Plan sections to reflect the procedure:
OBJECTIVE (Update):
Effusion: Moderate effusion confirmed. Knee aspiration performed today.
25 mL of [straw-yellow / turbid / blood-stained] fluid aspirated via
superolateral approach under sterile conditions. Post-aspiration:
effusion markedly reduced. Joint line now more accessible to palpation.
PLAN (Update):
- Synovial fluid sent for: cell count, culture/sensitivity, crystal
analysis
- Await fluid analysis results
- Review results in 24-48 hours
- [If septic arthritis suspected: IV antibiotics initiated / ortho
consult made]
- Patient educated on wound care and warning signs
Part 3: Interpreting and Documenting Fluid Findings
Once your lab results return, document the synovial fluid classification. This is what you are looking for:
| Fluid Type | Appearance | WBC Count | PMN % | Interpretation |
|---|---|---|---|---|
| Normal | Clear, colorless | < 200/mm³ | < 25% | Non-inflammatory |
| Non-inflammatory | Yellow, clear | 200-2,000/mm³ | < 25% | OA, trauma |
| Inflammatory | Yellow, turbid | 2,000-50,000/mm³ | > 50% | Gout, RA, pseudogout |
| Septic | Turbid, purulent | > 50,000/mm³ | > 90% | Septic arthritis |
| Hemarthrosis | Bloody/red | Variable | - | Trauma, ACL tear, fracture |
| Lipohemarthrosis | Blood + fat globules | - | - | Intra-articular fracture (tibial plateau) |
"A lipohemarthrosis, identified by fat droplets in the aspirate, suggests a fracture, classically seen in knee arthrocentesis with an occult tibial plateau fracture." - Rosen's Emergency Medicine
"Septic arthritis classically presents with >50,000/mm³ WBC in synovial fluid; levels >90% PMN are generally associated with infection." - Rosen's Emergency Medicine
Part 4: Real-World Example - Complete Note
Here is what a fully written note looks like for your scenario:
PROCEDURE NOTE - LEFT KNEE ARTHROCENTESIS
Date: 03/07/2026 | Time: 14:30 | Operator: Dr. [Name]
Indication: Left knee effusion following twisting injury 2 days ago. Aspiration performed for diagnostic and therapeutic purposes (pain relief, rule out hemarthrosis/septic arthritis).
Consent: Informed verbal consent obtained. Risks (infection, cartilage injury, bleeding), benefits, and alternatives explained.
Position: Supine, left knee flexed 20° with rolled towel support.
Site: Superolateral approach - 1 cm superior and lateral to the left patella. Skin cleaned with chlorhexidine. Sterile field maintained throughout.
Anesthesia: 2 mL of 1% plain lidocaine subcutaneously at insertion site.
Technique: 18-gauge needle on 20 mL syringe inserted through marked site, directed posteriorly under the patella. Entry into joint space confirmed by free flow of fluid. Gentle compression of suprapatellar pouch applied. Syringe exchanged once under sterile conditions.
Fluid obtained: 25 mL of straw-yellow, slightly turbid fluid. No gross blood or fat globules noted.
Samples sent: Cell count + differential, Gram stain + C&S, crystal analysis (polarized light microscopy).
Post-procedure: Needle removed, pressure applied x 2 minutes, sterile adhesive dressing applied. Effusion clinically reduced post-aspiration. Distal neurovascular status intact - DP/PT pulses present bilaterally, sensation normal. Patient comfortable.
Plan: Review synovial fluid results within 24 hours. Patient advised rest, avoid impact activity for 24 hours, and to return if fever, worsening pain, or redness develops.
Key Points to Always Include
| Must Document | Why |
|---|---|
| Volume (e.g. 25 mL) | Quantifies effusion size; baseline for comparison |
| Fluid appearance/color | First diagnostic clue - clear vs. turbid vs. bloody |
| Approach and needle size | Reproducibility; medicolegal record |
| Sterile technique confirmed | Medicolegal; infection prevention |
| Samples sent + tests ordered | Links procedure to diagnostic workup |
| Post-procedure neurovascular check | Detects immediate complications |
| Patient tolerance | Standard medicolegal language |
| Follow-up instructions given | Continuity of care |
Sources:
- Textbook of Family Medicine, 9th Ed. - Aspiration of Knee Joint
- Rosen's Emergency Medicine - Arthrocentesis and Synovial Fluid Analysis
- Rheumatology 2-Volume Set (Elsevier, 2022) - Indications for Aspiration
- WikEM Procedure Sample Documentation
- StatPearls: Synovial Fluid Analysis
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