ISCE

WIPER

LOOK

FEEL

MOVE

SPECIAL TESTS

CHECKLIST

An example of how you can start your station is as follows, "Hello, my name is *first-name *surname and I am a second year medical student. Can I just confirm your name and date of birth? Today I am here to examine your knees which will involve me having a look at them, feeling around them and asking you to perform some movements for me, is that okay with you? Are you in any pain before we start? I will require you to expose yourself below the knees for this examination, you may leave your shorts on." For the knee exam, you may inspect around the bed for objects such as walking aids and any prescription charts which give you a general overview of the patient's health. You may also do a general inspection of the patient for any muscle wasting and or/ the patient's body habitus which acts as a potential risk factor for joint pathologies. You may also inspect for any scars or bruising which can indicate previous surgeries or injuries.

Look - with patient standing first Inspect the knee from the front, side and back for any scars, swellings, deformities and muscle wasting. Scars - Note location and healing. You may ask the patient if they have had any previous surgeries. Bilateral knee replacement scars Swelling - Patients may have fluid in their knee and thus doing a patellar tap as further explained in the 'FEEL' section of this document would be helpful. Also look for swelling in the popliteal fossa. Make sure to note location and size of swelling. Knee effusion Muscle wasting - Most long-term knee pathologies cause quadriceps muscle wasting. Quadriceps atrophy Redness - Note location and extent Redness in a young boy Once you have completed that, assess the patient's gait by asking them to walk across the room At the end of gait assessment, the patient should be asked to lie down on the couch/ bed for further assessment. While the patient is now laying down, closely inspect the patient's knees for any of the above and/ or bruising, effusions. Knee bruising

The knee is a hinge joint that can only perform two movements - flexion and extension Always assess active movements first followed by passive movements if required. Ask the patient to fully bend the knee (flexion) and assess the distance between the back of the heel and the buttock and compare both sides. Then ask the patient to fully straighten their knee to assess knee extension. Normally the knee will be flat on the bed and you will not be able to put a hand between the bed and the knee. A knee that is not fully straight suggests a flexion deformity which can either be in the knee or hip. Ask the patient to do a straight leg raise. Ability to do this confirms continuity of the extensor mechanism (Quadricep muscle, patella and patellar ligament) If the patients active movements are not full then you may help them by passively flexing/ extending their knees. You should not do passive movements if the patient is in pain. Passive movements may also reveal crepitus which may be associated with osteoarthritis.

Feel - with the patient lying down and legs straight first Before starting, ask if the patient is in any pain. If they say yes, avoid that area if possible or examine it last and re-assure the patient that you will be as gentle as possible. Remember the 3 Ts when feeling the patient's knee: Temperature - assess the patient's temperature on the knees as well as above and below to compare. Generally, the back of your hand gives a more sensitive indication of temperature. Tenderness - Examine tenderness in a sequential manner. Examine for any pain over the lateral and medial joint lines which could indicate arthritis or meniscal problems. Also feel over the patellar and it's ligament as well as its insertion points, and over the medial and lateral tibia and femoral condyles. Tap (Patella tap) - As the patient is supine with their legs straight, like the fluid down from the supra-patellar pouch towards the knee and with 2/ 3 fingers on the other hand gently push the patella down. If there is an effusion the patella will feel spongey rather than firm. A positive patella tap indicates a moderate-large effusion. Feel - with the patient bending their knees Ask the patient to bend their knees and assess the ligaments around the knee joint, feel the popliteal fossa for any swelling (Indication of a popliteal cyst or commonly known as Baker's cyst) and the popliteal pulse. You may also feel for the tibial tuberosity and the head of the fibula.

You will be required to do 4 special tests for this examination; Anterior and Posterior drawer test - While the patient is supine with their knee flexed to 90 degrees, place both your hands on the upper tibia with your thumbs over the tibial tuberosity and index fingers under the hamstrings to make sure they are relaxed. Use your forearm to stabilise the lower tibia or sit on the patient's feet (Having gotten consent from them for this and if they aren't in any pain or are uncomfortable). Pull forward gently on the upper tibia (anterior drawer test) and push back on the upper tibia (posterior drawer test). Compare both knees. Anterior drawer test Posterior drawer test What does the test suggest? If the patient's tibia moves forward excessively during the anterior drawer test, this suggests damage to the anterior cruciate ligament; and if the tibia moves back excessively during the posterior drawer test, this suggests damage to the posterior cruciate ligament. Valgus stress test (Testing the medial collateral ligament) - While the patient is lying supine with their knee flexed to 15 degrees and one of your hand on the lateral aspect of their knee, pull out on the lower tibia with your other hand (as if you are trying to bend the knee outward) If there is laxity (give-way) and pain during this test, it suggests a tear in the medial collateral ligaments. Varus stress test (Testing the lateral collateral ligament) - While the patient is lying supine with their knee flexed to 15 degrees and one of your hand on the medial aspect of their knee, push in on the lower tibia with your other hand (as if you are trying to bend the knee inwards) This completes the examination. Thank the patient and summarise your findings to the examiner. An example summary is: "Today I performed a knee examination on a *20 year-old *gender named *first-name *surname. On general inspection of the bed there were no objects or medical equipment of relevance. The patient appeared comfortable at rest with no peripheral stigmata of musculoskeletal disease. The patient had a normal gait with a full range of movement on both knees. There were o abnormalities on palpation and on assessment of the ligaments of the knee. In summary, this was a normal knee examination" Note: Please summarise your findings in accordance to your examination i.e. mention any pain or abnormalities that you find.

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WIPER

LOOK

FEEL

MOVE

SPECIAL TESTS

CHECKLIST

An example of how you can start your station is as follows, "Hello, my name is *first-name *surname and I am a second year medical student. Can I just confirm your name and date of birth? Today I am here to examine your back and spine which will involve me having a look at your back while you're standing up and bending forward, feeling around your back and asking you to perform some movements for me, is that okay with you? Are you in any pain before we start? I will require you to be exposed above the waist for this examination, however, you may leave your shorts and/ or bra on." For the spine exam, you may inspect around the bed for objects such as walking aids and any prescription charts which give you a general overview of the patient's health. You may also do a general inspection of the patient for any muscle wasting and or/ the patient's body habitus which acts as a potential risk factor for joint pathologies. You may also inspect for any scars or bruising which can indicate previous surgeries or injuries.

Look - while the patient is standing Look at the patient from the front, the side and from the back. Assess the patient's spine for normal thoracic kyphosis and lumbar lordosis as well as any spinal deformities, exaggerated kyphosis, skin changes or any scars. Scoliosis Hyper-kyphosis Surgical scar

WIPER

LOOK

FEEL

MOVE

SPECIAL TESTS

CHECKLIST

WIPER

INSPECTION

TONE

REFLEXES

SENSATION

COORDINATION

POWER

CHECKLIST

WIPER

INSPECTION

TONE

REFLEXES

SENSATION

COORDINATION

POWER

CHECKLIST

ISCE

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