Both the knee and the shoulder examinations follow the same simple structure - Look, Feel, Move, Special Tests, Function. In an OSCE situation, make sure to check the card as to which shoulder/knee you've been asked to examine, either one or both. In all situations you'll be comparing the 'normal' joint to the 'problem' joint, so the following steps are to be done on both sides, beginning with the normal joint.
As with all the examinations, begin with the same opening sequence. Being friendly and rewording questions to make them sound less rehearsed will make your bedside manner appear much more natural and confident.
- Wash hands
- Introduce yourself
- Confirm their name, age and date of birth (try and remember the first 2 for your closing summary!)
- Consent eg. I've been asked to examine your knee today which will involve having a look, feel and move around of your knee - is that alright with you? - Again, rephrase to what you feel most natural saying.
- Check for pain or problems in movement
- Expose the patient appropriately (remove trousers or at least thigh to mid calf)
There are number of things that you need to look for and comment on their presence or absence. Although you will probably learn the list of what to say, make sure you're actively looking all around both knees, they'll know if you're just rattling out a list and not paying any attention to the patient.
- Asymmetry or abnormal posture
- Erythema or any other discolouration/skin changes
- Muscle wasting
Remember before touching the patient to always ask their permission. I'm now going to feel over both of your knees starting with the 'normal' side, is that ok? If you feel any pain during the examination then please let me know. Remember also to maintain eye contact with the patient so you can show the examiner you are focused on the patient and any potential pain or discomfort.
- Compare the TEMPERATURE over both knees and surrounding areas using the back of your hand.
- With the leg straight and using two fingers, palpate for TENDERNESS over the border of the patella
- With the legs flexed to 90 degrees palpate for swelling over the whole knee joint. Make sure to include the quadriceps tendon, around the patella, patella tendon, joint lines and insertion of ligaments.
- Feel behind the knee for a Baker's cyst.
- Check for EFFUSIONS using the patella tap test (push all the fluid down to over the patella and press down with a finger.
- Assess for FLUID by sweeping to one side of the knee and looking for any bulges.
Movements and Special Tests
- ACTIVE MOVEMENT - Can you flex and extend your knees for me please?
- PASSIVE MOVEMENT - Ask them to give you the weight of their leg, and flex/extend the knee with your other hand on top of the knee to feel for any crepitus.
- CRUCIATE LIGAMENTS - With the knees flexed to 90 degrees, inspect from the side for any posterior sag. Then sit on the bed with your thumbs either side of the tibial tuberosities and your elbow stabilising the lower leg. Pull sharply forward and then back for the anterior/posterior draw test.
- COLLATERAL LIGAMENTS - With the knees flexed to 15 degrees, take the weight of the leg and assess the stability of the ligaments by moving lower leg side to side.
There is no tenderness or laxity in the cruciate or collateral ligaments is a good phrase to use now.
- Can you stand up for me please? Inspect the back of the knees using the same list as above, and then check for fullness in the popliteal fossae or obvious Baker's cysts.
- Can you walk to the curtain and back for me please? Check for any abnormal gait.
As always, end your examination by thanking the patient, allowing them to cover themselves up, and washing your hands.
SUMMARY - as at the end of every examination you will be asked to summarise your findings. Begin with their name and age, and then briefly comment on each section before finishing with an overall statement such as this was a normal shoulder examination.
For more information on the knee exam and to see a demonstration please refer to this video, created by All Access Medicine: