Palpation

Ask the patient to sit on the edge of the examining table with the knees in flexion. In this position, bony landmarks are more visible and the muscles, tendons, and ligaments are more relaxed, making them easier to palpate.

First review the important bony landmarks of the knee. Facing the knee, place your thumbs in the soft-tissue depressions on either side of the patellar tendon. On the medial aspect, move your thumb upward and then downward and identify the medial femoral condyle and the upper margin of the medial tibial plateau. Trace the patellar tendon distally to the tibial tubercle. The adductor tubercle is posterior to the medial femoral condyle.

Lateral to the patellar tendon, identify the lateral femoral condyle and the lateral tibial plateau. The medial and lateral femoral epicondyles are lateral to the condyles with the knee in flexion. Locate the patella.

Lateral to the patellar tendon, identify the lateral femoral condyle and the lateral tibial plateau. The medial and lateral femoral epicondyles are lateral to the condyles with the knee in flexion. Locate the patella.

Tallo Cerebral
Palpate the ligaments, the borders of the menisci, and the bursae of the knee, paying special attention to any areas of tenderness. Pain is a common complaint in knee problems, and localizing the structure causing pain is important for accurate evaluation.

In the patellofemoral compartment, palpate the patellar tendon and ask the patient to extend the leg to make sure the tendon is intact.

With the patient supine and the knee extended, push the patella against the underlying femur. Ask the patient to tighten the quadriceps as the patella moves distally in the trochlear groove. Check for a smooth sliding motion (the patellofemoral grinding test).

Tenderness over the tendon or inability to extend the leg suggests a partial or complete tear of the patellar tendon.

Pain and crepitus suggest roughening of the patellar undersurface that articulates with the femur. Similar pain may occur with climbing stairs or getting up from a chair.

Now assess the medial and lateral compartments of the tibiofemoral joint. Flex the patient's knee to about 90°. The patient's foot should rest on the examining table. Palpate the medial collateral ligament (MCL) between the medial femoral epicondyle and the femur; then palpate the cordlike lateral

Pain with patellar movement during quadriceps contraction suggests chondromalacia, or degenerative patella.

MCL tenderness after injury is suspicious for an MCL tear. (The LCL is less subject to injury.)

collateral ligament (LCL) between the lateral femoral epicondyle and the fibular head.

Palpate the medial and lateral menisci along the medial and lateral joint lines. It is easier to palpate the medial meniscus if the tibia is internally rotated. Note any swelling or tenderness.

Note any irregular bony ridges along the joint margins.

Try to feel any thickening or swelling in the suprapatellar pouch and along the sides of the patella. Start 10 centimeters above the superior border of the patella (well above the pouch) and feel the soft tissues between your thumb and fingers. Move your hand distally in progressive steps, trying to identify the pouch. Continue your palpation along the sides of the patella. Note any tenderness or warmth greater than in the surrounding tissues.

Check three other bursae for bogginess or swelling. Palpate the prepatellar bursa, and over the anserine bursa on the posteromedial side of the knee between the medial collateral ligament and the tendons inserting on the medial tibial and plateau. On the posterior surface, with the leg extended, check the medial aspect of the popliteal fossa.

Tenderness from tears following injury are more common in the medial than in the lateral meniscus.

Bony ridges along the joint margins may be felt in osteoarthritis.

Swelling above and adjacent to the patella suggests synovial thickening or effusion in the knee joint.

Thickening, bogginess, or warmth in these areas indicates synovitis or nontender effusions from osteoarthritis.

Prepatellar bursitis ("housemaid's knee") from excessive kneeling. Anserine bursitis from running, valgus knee deformity, fibromyalgias, osteoarthritis. A popliteal or "baker's" cyst from distention of the gastrocnemius semimembra-nosus bursa

Three further tests will help you detect fluid in the knee joint.

■ The Bulge Sign (for minor effusions). With the knee extended, place the left hand above the knee and apply pressure on the suprapatellar pouch, displacing or "milking" fluid downward. Stroke downward on the medial aspect of the knee and apply pressure to force fluid into the lateral area. Tap the knee just behind the lateral margin of the patella with the right hand.

A fluid wave or bulge on the medial side between the patella and the femur is considered a positive bulge sign consistent with an effusion.

■ The Balloon Sign (for major effusions). Place the thumb and index finger of When the knee joint contains a your right hand on each side of the patella; with the left hand, compress the suprapatellar pouch against the femur. Feel for fluid entering (or ballooning into) the spaces next to the patella under your right thumb and index finger.

large effusion, suprapatellar compression ejects fluid into the spaces adjacent to the patella. A palpable fluid wave signifies a positive "balloon sign." A returning fluid wave into the suprapatellar pouch confirms an effusion.

■ Ballotting the patella. To assess large effusions, you can also compress the suprapatellar pouch and "ballotte" or push the patella sharply against the femur. Watch for fluid returning to the suprapatellar pouch.

Palpable fluid returning into the pouch further confirms the presence of a large effusion.

A palpable patellar click with compression may also occur, but yields more false positives.

Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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