Systematic Palpation

For Medical Students

What It Tests

Systematic palpation tests the structures around the knee one at a time, in a fixed order, so that what is found does not depend on what was suspected.

The knee is superficial. Most of its important structures can be felt, which makes palpation more informative here than at the hip or the shoulder. 2.1.1 covers the gross anatomy.

The value is in the system. An examiner who palpates where the patient points finds what the patient already knows; an examiner who follows a route finds what nobody has mentioned. 4.1.4 covers the structured approach.

How It Is Performed

Start with temperature, with the back of the hand, comparing both knees and the thigh and calf of each. 4.6.2 covers it.

Assess for an effusion before anything that hurts, because a tender knee stops cooperating. 4.6.3 covers that assessment.

With the knee flexed to ninety degrees, palpate the joint line from the patellar tendon round medially to the posteromedial corner, then from the tendon round laterally. 4.6.4 covers joint line tenderness.

Palpate the patella: its borders, its facets with the knee relaxed, and the tendon above and below it. 4.6.5 covers patellar tenderness.

Palpate the collateral ligaments along their courses, the tibial tubercle, the fibular head and the pes insertion. 4.6.7 covers the tubercle.

Finish with the back of the knee, with the knee extended and the patient standing if a cyst is suspected. 4.6.10 covers the popliteal fossa.

What a Positive Means

Tenderness localises a problem to a structure more precisely than any other part of the examination, which is its whole contribution.

Joint line tenderness means the meniscus, the deep ligament or the joint surface, and the three are separated by what provokes the pain rather than by its location. 4.12.7 covers that separation.

Tenderness over a ligament's course with no increased laxity is a sprain and is treated as pain. 4.12.3 covers the grade it is distinguished from.

Tenderness over the fibular head raises an avulsion or a corner injury and prompts a nerve examination. 4.6.8 covers it.

Warmth with tenderness and an effusion raises infection or inflammation and changes the pathway. 4.3.6 covers skin changes.

MRCS Level

How It Is Performed

In a viva palpation is where a candidate either has a route or does not, and having one is visible within seconds.

The expected points are temperature first, the effusion, the joint line with the knee flexed, the patella, the ligaments, the bony points, and the back of the knee last.

Say why the knee is flexed for the joint line, because flexion opens the joint line and makes the anterior horns accessible. 4.6.4 covers it.

Say that you would palpate the asymptomatic side first, which establishes the normal and gains the patient's confidence. 4.1.2 covers the principle.

Say that you would record where the tenderness is rather than which structure you think it is, since the location survives and the attribution may not. 4.1.8 covers the record.

What a Positive Means

The reasoning expected is that the knee's structures lie in predictable relationships to palpable landmarks, so a tender point can be assigned to a structure by its position. 2.1.7 covers surgical anatomy.

The joint line is the landmark that matters most, because the meniscus, the deep medial ligament and the articular surfaces all meet there and nothing else does. 2.5.1 covers the medial meniscus.

Flexing the knee rotates the tibia relative to the femur and opens the anterior joint line, which is why the position changes what can be reached. 3.3.2 covers roll and glide.

Tenderness is a symptom rather than a sign in the strict sense, which is why it localises well and grades badly, and why the provocation tests exist. 4.9.3 covers one of them.

How Good It Is

Palpation is the most specific localising part of the knee examination and the least able to grade anything.

Joint line tenderness is the most useful single palpation finding and is also non specific between the structures that meet there. 4.6.4 covers it.

It depends on patient cooperation and on the examiner's care rather than on force, which makes it more reproducible than the ligament tests in an acute knee.

It is unreliable in an obese patient, where the landmarks are hard to find, and in a patient who is tender everywhere. 4.23.4 covers those patients.

No figures appear for any accuracy comparison on this page, under decision 023, and the comparison is the claim being made.

FRCS Level

How Good It Is

At decision level palpation narrows the differential and rarely decides an operation, which is an honest description of a useful contribution.

Where it does decide something is in the acute knee, where a tender fibular head or a tender joint line changes the imaging requested and occasionally the urgency. 4.6.8 covers the fibular head.

It also decides whether a complaint has a localised source at all. A patient with diffuse tenderness and no localising point has a different problem from one with a single tender spot, and the distinction affects what is offered. 4.2.1 covers pain.

In the chronic knee palpation of the joint line and the compartments contributes to the question of whether the surface is the problem, which changes the category of treatment. 4.9.11 covers meniscal examination in osteoarthritis.

In the post-operative knee palpation over the hardware, the portals and the graft harvest site localises pain that the patient cannot. 4.3.7 covers surgical scars.

Where It Misleads

The commonest error is palpating where the patient points, which finds nothing new.

The second is palpating a tender knee before assessing the effusion and the temperature, after which the patient will not cooperate.

The third is attributing joint line tenderness to the meniscus by default. 4.12.7 covers the alternatives.

The fourth is palpating with the knee extended, where the joint line is closed and the anterior horns cannot be reached.

The fifth is omitting the back of the knee, which is where the findings that are missed live. 4.6.9 covers it.

Fellowship Level

Where It Misleads

In referred practice palpation is often the part of the examination that was performed least carefully, and repeating it properly answers a surprising number of referrals.

A patient referred with a ligament complaint whose only finding is tenderness over the pes insertion or the medial collateral's course has a soft tissue problem treated as a ligament one. 4.6.6 covers tendon tenderness.

A patient with a reconstruction and localised tenderness over a tunnel or a fixation device has a hardware problem, and palpation is the only examination that finds it. 4.3.7 covers scars.

A patient with posteromedial joint line tenderness sitting more posteriorly than usual may have a root or meniscotibial problem, and the exact location is the clue. 4.9.9 covers meniscal root tears.

A patient tender over several unrelated structures, with a normal examination otherwise, has a pain presentation rather than a structural one, and recognising that prevents a futile operation. 4.2.1 covers pain.

In medicolegal work a recorded tender point is weak evidence, since tenderness is a reported symptom rather than an observed sign, and that limit should be stated. 4.23.7 covers that setting.