The examination of the knee is performed with the patient standing and lying on the back.

While the patient is standing, any varus or valgus deformity should be noted. Is there wasting of the quadriceps muscle? Is there swelling of the knee? An early sign of knee joint swelling is loss of the slight depressions on the lateral sides of the patella. Inspect for swelling in the popliteal fossa. A Baker's cyst in the popliteal fossa may be responsible for swelling in the popliteal fossa, causing calf pain.

The patient is then asked to lie on the back. The contours of the knee are evaluated. The patella is palpated in extension for tenderness. By stressing the patella against the femoral condyles, pain may be elicited. This occurs in osteoarthritis.

Testing for knee joint effusion is performed by pressing the fluid out of the suprapatellar pouch down behind the patella. Start about 15 cm above the superior margin of the patient's patella and slide your index finger and thumb firmly downward along the sides of the femur, milking the fluid into the space between the patella and the femur. While you maintain pressure on the lateral margins of the patella, tap on the patella with the other hand. This technique is termed ballottement. In the presence of an effusion, a distinct bump is felt in response to your tap, and the transmitted impulse is felt by the fingers on either side of the patella. This technique is shown in Figure 20-45.

To palpate the collateral ligaments, the patient's foot should be resting on the bed, with the knee flexed at 90°. Grasp the patient's leg and, using your thumbs, try to elicit tenderness over the patellar tendon beneath the femoral epicondyles. This technique and a medial collateral ligament rupture are illustrated in Figure 20-46.

Another test for collateral ligament rupture is performed by placing the examiner's left hand on the lateral aspect of the patient's knee at the level of the joint. The knee is flexed about 25°, and the lower leg is pushed outward by the examiner's right hand, with the left hand acting as a fulcrum. This maneuver is an attempt to ''open up'' the medial side of the knee joint. The result should be compared with that on the other side. Abnormal lateral motion is seen in rupture of the medial collateral ligament, as illustrated in Figure 20-47. The maneuver can be used to test for rupture of the lateral collateral ligament by reversing the positions.

The drawer test is used to test for rupture of the cruciate ligaments. The patient is instructed to flex the knee to 90°. The examiner should sit close to the foot to steady it. The examiner then grasps the leg just below the knee with both hands and jerks the tibia forward, as illustrated in Figure 20-48. Abnormal forward mobility of 2 cm or more is suggestive of rupture of the anterior cruciate ligament. This maneuver can be used to test the posterior cruciate ligament by flexing the knee to 90°, steadying the foot, and attempting to jerk the leg backward. Abnormal backward motion of 2 cm or more indicates rupture of the posterior cruciate ligament.

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