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Review Article

Physical Examination of the Knee: Meniscus, Cartilage, and Patellofemoral Conditions

Bronstein, Robert D. MD; Schaffer, Joseph C. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: May 2017 - Volume 25 - Issue 5 - p 365-374
doi: 10.5435/JAAOS-D-15-00464
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Abstract

Because of its location and function, the knee is one of the most frequently injured joints in the body. Diagnosis of an injury requires a thorough knowledge of the anatomy and biomechanics of the joint. Many of the tests currently used to help diagnose the injured structures of the knee were developed before the availability of advanced imaging. However, several of these examinations are as accurate or, in some cases, more accurate than state-of-the-art imaging studies.

To evaluate knee pathology, familiarity with examination techniques for the menisci, extensor mechanism, patellofemoral conditions, and osteochondritis dissecans (OCD) and with the associated anatomy and biomechanics is essential. Methods that increase diagnostic sensitivity and accuracy should be incorporated. Advanced imaging, such as MRI, can then be used as necessary but should not replace the history and physical examination. We have previously described the ligamentous examination.1

General Examination

When a patient reports a knee injury, the clinician should first obtain a good history. The location of the pain and any mechanical symptoms should be elicited, along with the mechanism of injury. From these descriptions, the structures that may have been stressed or compressed can be determined and a differential diagnosis can be formulated. Previous injuries should also be sought because the current injury may be the sequela of a prior insult.

As with any physical examination, an orderly routine is of great importance. When the knee is evaluated, the sequence should involve inspection, assessment of active and passive range of motion (ROM), palpation, and special tests, with any potentially uncomfortable tests performed last.

To ensure a thorough examination, both of the patient’s lower extremities should be fully exposed. An assessment of gait should be performed first, looking for varus or valgus, quadriceps avoidance, and antalgic gaits. Substantial primary varus or valgus deformity may be the result of single-compartment osteoarthritis. With quadriceps avoidance, the patient bears weight with a knee locked in extension because of either a weakened extensor mechanism or pain. An antalgic gait can result from any condition causing knee pain.

Next, an assessment of standing limb alignment should be performed, taking note of specifics, such as pes planus and excessive femoral anteversion, both of which can contribute to patellofemoral tracking problems. Excessive femoral anteversion may be identified by an inward-pointing or so-called squinting patella.

The patient should then be positioned supine on an examination table. The uninjured knee should be examined first. This relaxes the patient and helps to reassure him or her that the examination will not cause pain, while also accounting for individual variations between the uninjured knee and the contralateral knee. We have found that telling the patient to relax his or her hip as well as the knee facilitates passive motion and instability examinations. The musculature, particularly the quadriceps, should be inspected for atrophy. In addition, the patella should be assessed for malalignment, which may predispose the patient to maltracking or patellar dislocation. Patella alta or baja is generally assessed with the patient in the seated position and can be confirmed radiographically.

Any localized swelling and masses, including swelling of the prepatellar bursa, a meniscal cyst, and Osgood-Schlatter disease of the tibial tubercle, should be noted. A popliteal (ie, Baker) cyst can be palpated posteriorly with the knee extended. Swelling of the distal femur or proximal tibia may indicate a neoplasm or infection.

The knee should be inspected for a prepatellar or intra-articular effusion. An effusion of the prepatellar bursa is anterior to the patella; with an intra-articular effusion, the patella remains palpable subcutaneously. On inspection, a true knee joint effusion is often best appreciated in the suprapatellar pouch. The effusion can be “milked” from the suprapatellar pouch with one hand, while the other hand palpates the effusion (Figure 1).

F1
Figure 1:
Clinical photograph demonstrating knee effusion by “milking” the fluid from the suprapatellar pouch with one hand. The other hand palpates the so-called balloon of fluid.

Next, ROM should be assessed, first with active motion and then with gentle passive motion if necessary. Compared with the contralateral knee, the injured knee may fail to reach full passive extension, which may indicate a mechanical block or hamstring spasm. Limited ROM is expected with large knee effusions or pain. Although full ROM is required for a complete knee examination, it is not always possible at the first visit and should not be forced. A short course of physical therapy with reexamination in several days to 1 week can be helpful.

Tenderness on palpation combined with knowledge of knee anatomy is especially useful for diagnosis. Palpation should be done systematically, altering the approach depending on the area of discomfort and examining the area of reported pain last. A suggested approach is to begin anteriorly and work posteriorly, starting with the quadriceps tendon and then palpating the patella, patellar tendon, and tibial tuberosity. Next, the medial and lateral patellar facets can be palpated while assessing for the apprehension sign. Then the medial and lateral joint lines should be palpated and the remainder of the examination performed, including specific tests for ligaments and menisci. As noted previously, any test that is expected to cause pain should be done last.

Finally, it is important to remember that pain felt in the knee may be referred from other locations, including the spine and the hip. A careful history can help differentiate referred spinal pain. Routine examination of the hip and spine is recommended when evaluating knee pain, with particular attention paid to loss of hip rotation.

The Menisci

The medial and lateral menisci are crescent-shaped cartilaginous structures, triangular in cross-section, that serve important biomechanical functions in the knee. These include load bearing, shock absorption, joint stability and congruity, joint lubrication, and proprioception. As early as 1803, Hey2 recognized injury to the meniscus as a cause for locking of the knee. The biology, anatomy, development, and degeneration of the meniscus were described by McMurray.3 The injury mechanism is typically a twisting moment through the knee in the flexed, weight-bearing position.4 Pain experienced at the time of injury is variable, followed by the insidious onset of an effusion over the next day. Patients may experience mechanical symptoms, such as catching, locking, clicking, or instability, and usually report either medial or lateral knee pain.

The lateral and medial menisci differ somewhat in anatomy. The lateral meniscus is more circular and mobile, whereas the medial meniscus is more firmly attached to the capsule and medial collateral ligament and is subject to greater forces. This predisposes the medial meniscus to more frequent injury.

An effusion combined with joint line tenderness (JLT) is one of the most sensitive and reliable signs of a meniscal tear.5 The joint line should be palpated through the full ROM to identify any subluxation or snapping of the hamstring over the medial condyle or the biceps tendons over the fibular head, which can confound findings.3 Tenderness over the more distal pes bursa should be differentiated from JLT.

McMurray Circumduction Test

McMurray3 described a circumduction test to detect occult tears of the posterior horns of the menisci. With the patient supine, the knee is fully flexed, and the examiner grasps the foot with one hand and steadies the knee with the other. The tibia is rotated internally and the knee is extended to test for a lateral meniscal tear and then externally rotated and extended to test for a medial meniscal tear (Figure 2). Anatomically, the posterior horn of the lateral meniscus is brought under the lateral femoral condyle with flexion and internal rotation and is stressed as the knee is extended. The medial meniscus is similarly entrapped with external rotation (Figure 3). Although McMurray3 described a palpable click or clunk, the maneuver has been modified so that pain along the tested joint line is considered notable. The test can be performed only when the patient has full knee flexion. Because the test is designed to displace an occult posterior horn tear, it may not be as useful for an already displaced meniscal tear.

F2
Figure 2:
A, Clinical photograph showing the lateral McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is internally rotated (white arrow), engaging the posterior horn of the lateral meniscus under the lateral femoral condyle. The knee is then extended (black arrow), entrapping the meniscus. B, Clinical photograph showing the medial McMurray circumduction examination. With the patient’s knee fully flexed, the tibia is externally rotated (white arrow), engaging the posterior horn of the medial meniscus under the medial femoral condyle. The knee is then extended (black arrow), entrapping the meniscus.
F3
Figure 3:
Photographs of a knee model demonstrating the anatomic principles of the McMurray circumduction examination, with internal rotation of the tibia and entrapment of the lateral meniscus (A) and external tibial rotation and entrapment of the medial meniscus (B).

Of note, McMurray3 did not mention varus or valgus stress. Some authors have added varus and valgus stress to medial and lateral McMurray circumduction tests, respectively,5-7 although we have not found this helpful.

Apley Grind Test

In 1947, Apley4 presented his own test, arguing that McMurray’s approach was flawed. He specifically aimed to differentiate “rotational sprain” from a meniscal tear, which he described as a capsular or collateral ligament sprain. As described by Apley,4 his test requires that the patient lie prone on an examination table no more than 2 ft high so that the examiner can place his or her knee over the patient’s posterior thigh, stabilizing the femur. With the knee flexed 90°, the examiner powerfully rotates the tibia externally, first neutrally loaded, next in distraction, and then in compression. Substantially increased pain in distraction compared with the neutral position indicates a rotational sprain, whereas increased pain in compression indicates a meniscal tear. Similar to McMurray,3 Apley4 noted that internal rotation can be applied to test the lateral meniscus and that a more acute knee flexion angle can be applied to test the posterior horn.

Because most clinical offices do not have a 2-ft–high table for conducting a test with substantial distraction, the Apley grind test is now more commonly performed with prone compression and rotation. We have found that patients with patellofemoral pain often have pain with prone compression and rotation, so we have mostly abandoned this test in our practice.

Diagnostic Accuracy of Meniscus Tests

Numerous primary studies have reported on the accuracy of various tests for diagnosing a meniscus injury, especially the JLT, McMurray circumduction, and Apley grind tests, and several groups have systematically reviewed this pool of data. The reported sensitivity and specificity of the tests have varied widely, and the published reviews have been limited by notable heterogeneity between studies; the variation has been attributed to methodological flaws in the study designs.8-11

The most comprehensive of these systematic reviews was conducted by Hegedus et al9 in 2007 and included 18 studies from English- and German-language publications. The reported sensitivity and specificity varied widely (from 15% to 74% and from 11% to 97%, respectively, for the McMurray circumduction test; from 27% to 95% and from 5% to 98%, respectively, for the JLT test; and from 13% to 70% and from 33% to 100%, respectively, for the Apley grind test). The pooled sensitivity and specificity, respectively, were 70.5% and 71.1% for the McMurray circumduction test, 63.3% and 77.4% for the JLT test, and 60.7% and 70.2% for the Apley grind test.

Another meta-analysis published soon after but including only 11 English-language articles indicated that the mean sensitivity and specificity were 55% and 77%, respectively, for the McMurray circumduction test; 76% and 77%, respectively, for the JLT test; and 22% and 88%, respectively, for the Apley grind test.10 This review,10 as well as another by Hing et al,11 confirmed the widely ranging values.

Generally speaking, the McMurray circumduction test has relatively high specificity but low sensitivity, whereas the JLT test is thought to have higher sensitivity but lower specificity.11-13 Furthermore, in studies that reported medial and lateral meniscus testing separately, the McMurray circumduction test had higher sensitivity medially but higher specificity laterally.11 Mariani et al14 suggested that differences in the anatomic attachments of the two menisci, with the medial being more fixed and the lateral being more mobile, contributed to this variation. More studies on the diagnostic accuracy of these tests have been published recently and generally agree with the trends reported in the systematic reviews.13,15-17

Thessaly Test

The Thessaly test, named for its region of origin in Greece, was described by Karachalios et al18 in 2005. The test is intended to be both easy to perform in the outpatient setting and more accurate in detecting meniscal tears than the existing provocative tests are. The Thessaly test is performed with the patient standing on one foot, which is fixed flat on the ground (ie, first the normal side for training, then the injured side), and with the knee at a fixed angle of flexion (ie, first at 5°, then at 20°). The examiner supports the patient by the hands, and the patient internally and externally rotates his or her body three times. This reproduces dynamic load transmission and stresses the meniscus. Medial or lateral joint line discomfort or popping constitutes a positive test result.

In the original article by Karachalios et al,18 the 20° Thessaly test had a medial sensitivity and specificity of 89% and 97%, respectively, and a lateral sensitivity and specificity of 92% and 96%, respectively; these results were superior to those of the 5° test as well as those of the McMurray circumduction, Apley grind, and JLT tests. A notable limitation was the exclusion of acutely injured knees (ie, <4 weeks).

A follow-up study of meniscal tears reported 90.3% sensitivity and 97.7% specificity for the 20° Thessaly test, confirming the original findings.19 In contrast, a second follow-up study could not repeat the diagnostic accuracy reported in the original paper, instead finding that the Thessaly test had accuracy similar to that of the McMurray circumduction test.15 Another recent study involving 593 patients with a suspected meniscal tear also reported lower accuracy with the Thessaly test (ie, 64% sensitivity and 53% specificity), although the results were not significantly different from rates observed with the McMurray circumduction test.20 One study showed that the Thessaly test was less accurate in the presence of anterior cruciate ligament tears, demonstrating that normal biomechanics are important with use of provocative maneuvers for meniscal tears.17

Composite Clinical Examination Versus Magnetic Resonance Imaging

Some authors have noted that considering diagnostic tests individually is somewhat incomplete and that diagnostic accuracy is increased when the tests are considered together.12 Indeed, despite the limitations of the individual tests for meniscal tears, combined testing has improved accuracy.8,15 Several studies have compared the diagnostic accuracy of a composite/combined clinical examination with that of MRI.21-25 Galli et al13 compared clinical examination with arthroscopic findings and concluded that a clinical evaluation by an experienced examiner is at least as accurate as MRI in detecting meniscal lesions and recommended proceeding directly to arthroscopy without further imaging after a positive McMurray circumduction test result. Rayan et al21 compared the composite physical examination (ie, including McMurray circumduction and JLT tests) with MRI, using arthroscopy as the benchmark; physical examination had 86% sensitivity and 73% specificity for medial meniscal tears, which was somewhat better than that of MRI, and 56% sensitivity and 95% specificity for lateral meniscal tears, which was comparable to findings with MRI. We are confident in proceeding to arthroscopy with positive meniscal test results in conjunction with a knee effusion and normal radiographs.

The Extensor Mechanism

The extensor mechanism is composed of the quadriceps muscles, the quadriceps tendon, the patella, and the patellar tendon and its insertion at the tibial tubercle. When ruptures of the extensor mechanism are identified early, outcomes (ie, repairs) are improved; however, the initial misdiagnosis rate is ≥39%.26,27

Quadriceps tendon tears usually occur in patients aged >40 years,27 whereas patellar tendon ruptures tend to be higher energy and occur in patients aged <40 years. The mechanism is usually an eccentric load, such as stepping in a hole, missing a stair step, or jumping. Patients typically report a painful, swollen knee, a sensation of giving way, and inability to walk unassisted. In addition, they hold their knee extended as much as possible.

Examination of the extensor mechanism, like that of other anatomic features of the knee, is guided by the patient history. A quadriceps or patellar tendon tear is diagnosed by the inability to extend the knee against gravity and a palpable defect directly proximal or distal to the patella, combined with a history of an acute injury. In larger patients, it may be difficult to palpate the defect, particularly a quadriceps tendon rupture. When a quadriceps or patellar tendon rupture is suspected and the defect cannot be palpated, advanced imaging can be helpful. Radiographs may also reveal patella alta or baja (ie, an Insall-Salvati ratio >1.2 or <0.8, respectively).28

Patellofemoral Conditions

The patella is a sesamoid bone with medial and lateral facets separated by a ridge or crest. The medial and lateral facets vary in relative size. The femoral trochlea provides bony stability but also varies in configuration and depth. The patellofemoral joint is stabilized passively by patellofemoral ligaments and retinacular constraints and is stabilized actively by the quadriceps stabilizers. Patellofemoral symptoms are generally classified as either pain or instability.29

Patellofemoral Pain

Patients commonly report anterior knee pain. Although a detailed explanation of the various etiologies of anterior knee pain is beyond the scope of this article, patellofemoral pain syndrome (PFPS) refers broadly to pain associated with patellofemoral articulation. The symptoms of PFPS are often exacerbated by prolonged sitting (ie, the so-called movie sign), climbing or descending stairs, or other activity. When patellofemoral pain is discussed, the term chondromalacia should be reserved for cases of physical damage to the articular cartilage, diagnosed radiographically or by arthroscopic visualization.

Tests for Patellofemoral Pain Syndrome

Physical examination findings for patellofemoral pain include tenderness about the joint. In 1936, Owre30 described a patellofemoral grinding test as follows: While the patient lies supine with the knee extended and relaxed, the examiner places his or her fingers over the patella and exerts pressure through the patella medially and laterally, moving it superiorly and inferiorly against the femoral trochlea; pain constitutes a positive test result. A more contemporary and common version of the patellar grind test is known as the Clarke sign or test, although to our knowledge, there is no record of its origin in the literature.31 It incorporates active contraction of the quadriceps while the examiner braces the patella in the web space of the thumb, exerting compressive and inferior pressure. These two patella compression tests are sometimes differentiated as passive versus active, but neither accurately reproduces normal patellofemoral mechanics.12

We prefer to palpate for patellar facet tenderness by moving the patella medially and laterally while palpating the medial and lateral facets, respectively, although this approach is still not specific. Tightness of the lateral retinacular structures, which causes patellar tilt, may be seen with PFPS. On examination, this is manifested as the inability to lift the lateral patella off the horizontal with the knee extended or to manually displace the patella medially greater than one quadrant of the patellar width with the knee flexed at 20° to 30° and relaxed32 (Figure 4). Tenderness over the quadriceps tendon or patellar tendon may indicate tendinitis or tendinopathy.

F4
Figure 4:
A, Illustration showing a normal passive patellar tilt test. With the knee extended and the quadriceps relaxed, an inability to lift the lateral patella off the horizontal indicates tight retinacular structures causing patellar tilt. B, Illustration showing the patellar glide test—30° of flexion. An inability to manually displace the patella medially at least one quadrant indicates a tight retinaculum. (Panel A reproduced from Dragoo JL, Tuman JL: Knee injuries and related conditions, in Limpisvasti O, Krabak BJ, Albohm MJ, et al: The Sports Medicine Field Manual. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2015, pp 337-361.)

Diagnostic Accuracy

A prospective validation study of 106 patients scheduled for arthroscopic knee surgery found the Clarke sign had a sensitivity of only 39.1% and a specificity of 67.5% in assessing chondromalacia patella,31 providing little to no diagnostic value. This finding was corroborated by other studies.12,33

The patellar tilt examination for patellofemoral pain had a sensitivity of 43% and a specificity of 92% in diagnosing PRPS.34 This test also had poor intraobserver and interobserver reliability in assessing patellar instability (κ = 0.05 and κ = 0.08, respectively).35

Further reviews have confirmed that although many tests have been described, to our knowledge there are no truly valuable physical tests for either chondromalacia patella or PFPS.31,33,36 Current test validation studies have been limited by the lack of a consistent reference standard. According to Cook et al,36 patellofemoral pain remains a “multifactorial and nebulous pathology,” which may be a diagnosis of exclusion.

Patellar Instability

Patellar instability is common, affecting young, active persons and females more than males, and can be debilitating.37 Patients with true patellar instability report either patella dislocation requiring reduction or lateral subluxation with spontaneous reduction.29 The cause is multifactorial; contributing factors include the bony structure of the patella and femoral trochlea, integrity and/or laxity of the surrounding tissues including the medial patellofemoral ligament, muscle tone and balance, and overall limb alignment.35,37,38

Q Angle

The quadriceps angle, or Q angle, is a measure of the direction of pull of the quadriceps relative to the line of action of the patella; this angle is theoretically important because it relates to the lateral displacement force on the patella. The Q angle is defined as the acute angle formed by lines drawn from the anterior superior iliac spine to the center of the reduced patella and from the center of the patella to the tibial tuberosity.39 An angle ≥20° is often cited as abnormal, as recommended by Insall et al.39 The effective Q angle can be increased by excessive femoral anteversion and by pes planus through tibial external rotation.

J Sign

The J sign is an indication of pathologic patellar tracking and refers to the inverted “J” course of the patella as it subluxates laterally in full extension and then reduces into the femoral trochlea in early flexion, observable with both active and passive motion.40,41 It is considered a sign of severe instability that is difficult to treat38,41 and has been associated with vastus medialis obliquus insufficiency;41 however, recent evidence shows it more likely indicates a ligamentous problem or trochlear dysplasia.42 Its clinical validity is questioned, however, because one study found the subjective J sign did not correlate with lateral patellar subluxation.42 Furthermore, although it had moderate interobserver reliability (ie, κ = 0.53), the J sign had poor intraobserver reliability (ie, κ = 0.28).34

Fairbank Apprehension Test

In 1937, Fairbank43 described a test for use in patients with suspected recurrent patellar dislocation. He noted that patients had marked apprehension when the patella was pushed outward. The result is considered positive only when the patient expresses apprehension or a feeling of instability, rather than pain. A positive sign is strongly suggestive of symptomatic patellar instability,41,43 and the specificity of the test has been moderately good (ie, 70% to 92%).36 The sensitivity of the test, however, has been low (ie, ≤37%),12,36 with little to no interobserver reliability.35 A patellar glide of more than two quadrants can indicate a lack of medial patellar restraints.

Osteochondritis Dissecans

OCD is a disease of uncertain etiology primarily in children and young adults that can lead to irreversible damage of articular cartilage and subchondral bone. It was first described by Paget44 in 1870 as “quiet necrosis” and was then termed “osteochondritis dissecans” by König45 in 1887. The suspected cause is a vascular insult to the subchondral bone that is possibly related to repetitive trauma and results in lamination and sequestration with or without damage to the overlying articular cartilage. Lesions occur primarily in the knee; most are located on the femur, with 70% on the lateral aspect of the medial femoral condyle.46

Patients typically report poorly localized knee pain that worsens with activity, particularly deep flexion activity, such as stair climbing. Mechanical symptoms may be reported and indicate an unstable lesion or loose body. On examination, there may be a mild effusion and point tenderness over the involved site.

Wilson Sign

In 1967, Wilson47 observed that patients with OCD of the medial femoral condyle often had a specific antalgic gait with external rotation of the foot, which he proposed relieves the pressure of the tibial spine on the medial femoral condyle. He then described a diagnostic test that incorporates this anatomic relationship. First, the patient is positioned supine with the knee flexed to 90° and the tibia rotated internally. Next, the knee is slowly extended. A positive test result is recorded when the patient reports pain as the tibial spine abuts the OCD lesion on the medial femoral condyle at approximately 30° short of full extension. The pain is relieved as the tibia is externally rotated, which brings the tibial spine away from the lesion (Figure 5).

F5
Figure 5:
Clinical photographs demonstrating the Wilson sign. A, The knee is first flexed to 90°, and the tibia is internally rotated (arrow). B, The knee is then slowly extended with the tibia kept internally rotated (arrow); the patient reports pain as the tibial spine abuts the osteochondritis dissecans lesion on the medial femoral condyle at about 30° short of full extension. C, The pain is relieved by externally rotating the tibia (arrow), bringing the tibial spine away from the lesion.

Diagnostic Accuracy

In a study of 32 patients, Conrad and Stanitski48 found that only 25% of patients with radiographic evidence of medial femoral condyle OCD had a positive Wilson sign at the initial visit; however, these patients converted to a negative Wilson sign with lesion resolution. This means that although the sign may not be sensitive, conversion from a positive to negative result is a good indicator of clinical healing.

No study has evaluated the diagnostic performance of the Wilson sign specifically. However, Kocher et al49 reported on the diagnostic accuracy of a composite clinical evaluation, including history, physical examination, and radiography, in pediatric patients with knee disorders. The authors found that for OCD, the composite clinical evaluation’s sensitivity was 77.3% and its specificity was 97.9%. This study has notable weaknesses, but it does illustrate that most OCD lesions are diagnosed primarily with radiography. Therefore, the physical examination—and the Wilson sign specifically—are probably of little clinical value by themselves; however, by indicating a need for imaging, they may lead to a correct diagnosis.

Summary

Knee pathology can be accurately diagnosed with a thorough patient history and physical examination. The described tests, along with an understanding of knee anatomy and biomechanics, can be used to reliably diagnose most meniscal and ligamentous injuries. Radiography should be performed for all patients with knee injury, and weight-bearing views should be obtained when arthritis is suspected. MRI, which can be helpful in some cases, is not always necessary and should never be performed in lieu of a history and physical examination.

References

Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 14, 17, 18, 33, 34, and 42 are level I studies. References 7, 15, 16, 20, 22, 23, and 28 are level II studies. References 8-11, 13, 19, 24, 25, 39, 48, and 49 are level III studies. References 4, 5, 21, 26, 27, 31, 32, 35, 43, and 47 are level IV studies. References 2, 3, 6, 12, 29, 30, 36-38, 40, 41, 45, and 46 are level V expert opinion.

References printed in bold type are those published within the past 5 years.

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Keywords:

knee; examination; meniscus; patellofemoral; OCD; osteochondritis dissecans

Copyright 2017 by the American Academy of Orthopaedic Surgeons.