History

Opening

• Wash hands
• I am Mr Puthezhath, Can I ask you a few questions?
• Can I know your name and age?
• Mr Joe,
  • How can I help you today?
  • I know you have a problem with left knee,how long it is going on ?
  • What make you come now?what made it worse and when?

ODP

• When? trauma or insedious
• Progression : better, worse, some days on /off
• Site: where the pain is? knee
• Do you get pain in the groin going down to knee
• Do you have pain in the buttock going down the back of knee and below it with pins and needles?

Pain

• Pain at rest
• Pain on getting up
• after how many minutes your knee stops you from walking
• Stair climbing
• Sleeping pain

SLID

• Swelling on/off
• Does your knee get stuck in one position and you can’t move it?
• Does your knee collapse under you? while pivoting/going down stairs (young)
• Deformity

Past knee

• 20 years ago what happened?
• What was done for the knee?
  • operations
  • pain killers
  • Physiotherapy
  • Stick
• Did you have any trauma, infection or fractures in the past?

Other joint history

Medical

• Allergy
• Do you have
  • DM
  • BP
  • resent heart attack or stroke
  • Breathlessness
  • Chest pain
  • Drugs
    • Blood thinners
    • Steroids
    • Any drug for inflammatory disease like RA
• Any operations that left you with leaking wounds

Social

• Work: do you work/ or have people working for you
• Smoking
• Activity stopped only due to knee pain

Summarise for the patient

• Have I missed any thing
• what are your examinations

Transition

• I am Mr Puthezhath. Can I examine your knee please?That involves look feel and move and me asking you to have a walk. Is that ok?
• Can you remove your trousers, shoes and socks and hand over your shoes for me to look
• and
• Do you use any stick or any other walking aid?

Shoes

• Look from side for external heel raise
• look inside for internal heel raise
• medial arch support
• Undue wear pattern on one side
• no stretch suggestive of bunion/bunionette

Look

• Look from front back and side.
• Swelling and wasting of quadriceps
• Scar and sinus
  • Midline 12 cm scar, Healed through out its length by primary intension with distal part healed by secondary infection
  • There is a sinus with redness around it
• varus/valgus/flexion/extension of knee and shortening

Look side

• Flexion attitude of knee and the foot is plantigrade/ equinous at ankle

Look from back

• Swelling/fullness of popletial fossa and hamstring/caff wasting
• Scar and sinus

Look joint above and below

• Pelvis is symmetrical and arches of feet looks symmetrical.

Gait

• Remove chair/ask examiner to move
• Please walk towards me turnaround and walk to the wall
• Thank you, please lie down
• Tell examiner: what gait it is.
  • Antalgic: short stance phase
  • Trendelenberg gait:
    • when patient stands on normal hip, pelvis on other side raises
    • when patient stands on bad hip, pelvis on the sound side sag
  • Waddling: bilateral trendelenberg
  • Short leg gait: When patient stands on short side pelvis dips down
  • Hig stepping gait: Foot drop
  • Scessoring, crouch, windswept
  • Circumdection, shuffling gait, broad based gait

Lie down

• His varus of left knee has improved/remains same.
• I would like to touch your knee with back of the hand looking temperature. Say warm or not to examiner.
• Let us bend your knee together. does it sore where my thumb is
  • front of knee
    • distal pole patella
    • top of patella
    • Gap in quadrips
  • medial and lateral
    • AL /AM
    • Mid lat/mid medial
    • PL/PM
    • Attachment of ligaments
  • Back
  • Knee in extension
    • medial and lateral patella facet

Test for effusion

• Get all fluid to knee by pushing down supra patellar pouch
• Tap on patella
• Remove hands
• Patella tap positive
• If negative
  • Filling and swipe test

Movement

Special test

• Quadriceps active
• Anterior drawer
• Lachman
• Valgus varus stress test

NV