Documentation of Exam
This may be used as a template or example of what you may want to include in the documentation of your knee exam. See below for the PDF of the Documentation for printing.
Inspection:
Documentation of Gait, stature. (Absence/presence) of knee effusion, ecchymosis, swelling, deformity or defect.
Range of motion of the knee:
Flexion to (xx degrees or full). Extension to (xx degrees or full)
Palpation:
(Tenderness/no tenderness) to palpation of (specific areas or landmarks)
Specific Testing:
(Positive/Negative) patellar grind, (Positive/Negative) patellar inhibition, (Positive/Negative) patellar apprehension, Patellar tracking (normal/abnormal)
(Tenderness/no tenderness) over MCL. (Laxity/no laxity) of the MCL with valgus at 0 degrees, 30 degrees
(Tenderness/no tenderness) over LCL (Laxity/no laxity) of the LCL with varus at 0 degrees, 30 degrees
(Positive/Negative) Anterior drawer, (Positive/Negative) posterior drawer, (Positive/Negative) Lachman and (Positive/Negative) PCL sag test
(Positive/Negative) Medial or lateral joint line tenderness, (Positive/Negative) McMurray's, (Positive/Negative) Apley's Compression Grind, (Positive/Negative)Bounce test (Positive/Negative) Noble's test
(Positive/Negative) Ober's test
Neurovascular exam:
Document dorsalis pedis and posterior tibial pulses and capillary refill time. Sensory exam.