Palpation
The purpose of palpating an injured patient is to acquire a feel for the underlying structures, including boney landmarks and soft tissue, as well as attempting to identify the severity of the injury. Palpation, in some cases, will cause a reproduction of pain, to be measured on a general pain scale, as well as allow the Athletic Trainer to recognize the amount of inflammation present, regarding the cardinal signs of inflammation. Palpation may also identify certain deformities within the local area of injury as well as crepitus within a joint, which may signify additional underlying conditons. Specific structures to be palpated, surrounding the knee are listed below:
**It is important to note that many of the most commonly injured structures cannot be palpated due to location or complications due to localized inflammation.**
**It is important to note that many of the most commonly injured structures cannot be palpated due to location or complications due to localized inflammation.**
Palpation of anterior structures in the knee
1. Patella - Begin palpating the patella at its superior patellar pole where the quadriceps muscle group inserts, noting for areas of point tenderness. Progress centrally down the patella to reach the inferior pole and the origin of the patellar tendon. Return to the starting point on the superior pole by palpating up the medial and lateral patellar borders. With the knee extended and the quadriceps relaxed, palpate the patella to ensure its proper alignment in the femoral trochlea and its freedom of movement. A dislocated patella can occur with or without the rupturing of the patellar tendon. A rigid, displaced patella accompanied by the inability or unwillingness to extend the knee generally indicates a dislocated patella
2. Patellar Tendon - Palpate the length of the patellar tendon from its insertion at the tibial tuberosity to the inferior aspect of the patella. The patellar tendon normally feels broad and ropelike. A chronic tendinopathy often results in palpable nodules within the mass of the tendon. The tendon can also be palpated while the patient performs active ROM of the knee, noting any crepitus indicating patellar tendinopathy.
3. Tibial Tuberosity - Palpate the patellar tendon's attachment site on the Tibia. The tibial tuberosity is normally a smooth, rounded protrusion. With adolescent patients, sensitivity and roughness of the tuberosity indicate an inflammation of the tibial tuberosity's growth center, or Osgood-Schlatter's disease. Pain in mature patients may be caused by a contusion or localized inflammation.
4. Quadriceps Tendon - From the superior aspect of the patella, palpate the quadriceps tendon as it attaches across the length of the patella's superior pole. Note that the suprapatellar pouch of the joint capsule and the suprapatellar fat pad lie deep to the quadriceps tendon. Fluids tend to accumulate because of the large capsular redundancy.
5. Quadriceps muscle grouping - Palpate these structures according to Figure 3 on the Anatomy tab of this website. These muscles include: the vastus medialis, the rectus femoris, and the vastus lateralis muscles. Note: The vastus intermedius is not directly palpable. Be sure to palpate these structures for point tenderness, functional deficit, defect or spasm.
6. Sartorius - Palpate the sartorius muscle from its origin on the anterior superior iliac spine (ASIS) to its insertion point at the pes anserine tendon.
(Starkey & Ryan, 2010)
2. Patellar Tendon - Palpate the length of the patellar tendon from its insertion at the tibial tuberosity to the inferior aspect of the patella. The patellar tendon normally feels broad and ropelike. A chronic tendinopathy often results in palpable nodules within the mass of the tendon. The tendon can also be palpated while the patient performs active ROM of the knee, noting any crepitus indicating patellar tendinopathy.
3. Tibial Tuberosity - Palpate the patellar tendon's attachment site on the Tibia. The tibial tuberosity is normally a smooth, rounded protrusion. With adolescent patients, sensitivity and roughness of the tuberosity indicate an inflammation of the tibial tuberosity's growth center, or Osgood-Schlatter's disease. Pain in mature patients may be caused by a contusion or localized inflammation.
4. Quadriceps Tendon - From the superior aspect of the patella, palpate the quadriceps tendon as it attaches across the length of the patella's superior pole. Note that the suprapatellar pouch of the joint capsule and the suprapatellar fat pad lie deep to the quadriceps tendon. Fluids tend to accumulate because of the large capsular redundancy.
5. Quadriceps muscle grouping - Palpate these structures according to Figure 3 on the Anatomy tab of this website. These muscles include: the vastus medialis, the rectus femoris, and the vastus lateralis muscles. Note: The vastus intermedius is not directly palpable. Be sure to palpate these structures for point tenderness, functional deficit, defect or spasm.
6. Sartorius - Palpate the sartorius muscle from its origin on the anterior superior iliac spine (ASIS) to its insertion point at the pes anserine tendon.
(Starkey & Ryan, 2010)
Palpation of Medial Structures in the knee
1. Medial meniscus and Joint line - Place the knee in at least 45 degrees of flexion to locate the joint lines. Palpate on either side of the proximal aspect of the patellar tendon until the indentation formed by the femur and tibia is located. Palpate medially and posteriorly along the joint line, noting any crepitus or pain that may indicate possible meniscal, ligamentous or capsular trauma. Externally rotating the tibia makes the border of the medial meniscus more palpable.
2. Medial collateral ligament (MCL) - Many sprains of the MCL occur at the origin or insertion of the ligament. Palpate the length of the MCL from its origin on the medial femoral condyle, just below the adductor tubercle, progressing inferiorly to its insertion on the medial tibial flare that can be located up to 7 cm distal to the joint line. The medial portion of the joint line is covered by the MCL. Note the close relationship between the tendons of the pes anserine group and the MCL.
3. Medial femoral condyle and epicondyle - Flex the knee beyond 90 degrees to better expose the articulating surface of the condyle immediately above the anteromedial joint line. The adductor tubercle, the attachment site for the adductor longus, projects off of the medial femoral condyle. Injuries with rotational or loading type mechanisms may cause bone bruising or osteochondral fracture, creating pain in the condyles.
4. Medial tibial plateau - Locate the medial tibial plateau inferior to the joint line. After palpating along its length, proceed inferiorly to locate the medial tibial flare, a structural necessity to disperse compressive forces at the articulation.
5. Pes anserine tendon and bursa - Locate the medial tibial flare, the site of attachment for the gracilis, sartorius and semitendinosus muscles. Palpate the common insertion of these tendons located just medial to the tibial tuberosity. Direct blows or overuse may cause these structures and the overlying pes anserine bursa to be inflamed. The pes anserine bursa may be more easily identified midway between the tibial tuberosity and the anterior aspect of the medial joint line if the tibia is slightly internally rotated.
6. Semitendinosus tendon - From the pes anserine attachment, palpate the semitendinosus tendon, the most medial tendon of the hamstring group, to its muscular belly.
7. Gracilis - Palpate the thin, ropelike gracilis, located immediately anterior to the semitendinosus tendon, from its insertion to the point that it is lost in the mass of the adductor group.
(Starkey & Ryan, 2010)
2. Medial collateral ligament (MCL) - Many sprains of the MCL occur at the origin or insertion of the ligament. Palpate the length of the MCL from its origin on the medial femoral condyle, just below the adductor tubercle, progressing inferiorly to its insertion on the medial tibial flare that can be located up to 7 cm distal to the joint line. The medial portion of the joint line is covered by the MCL. Note the close relationship between the tendons of the pes anserine group and the MCL.
3. Medial femoral condyle and epicondyle - Flex the knee beyond 90 degrees to better expose the articulating surface of the condyle immediately above the anteromedial joint line. The adductor tubercle, the attachment site for the adductor longus, projects off of the medial femoral condyle. Injuries with rotational or loading type mechanisms may cause bone bruising or osteochondral fracture, creating pain in the condyles.
4. Medial tibial plateau - Locate the medial tibial plateau inferior to the joint line. After palpating along its length, proceed inferiorly to locate the medial tibial flare, a structural necessity to disperse compressive forces at the articulation.
5. Pes anserine tendon and bursa - Locate the medial tibial flare, the site of attachment for the gracilis, sartorius and semitendinosus muscles. Palpate the common insertion of these tendons located just medial to the tibial tuberosity. Direct blows or overuse may cause these structures and the overlying pes anserine bursa to be inflamed. The pes anserine bursa may be more easily identified midway between the tibial tuberosity and the anterior aspect of the medial joint line if the tibia is slightly internally rotated.
6. Semitendinosus tendon - From the pes anserine attachment, palpate the semitendinosus tendon, the most medial tendon of the hamstring group, to its muscular belly.
7. Gracilis - Palpate the thin, ropelike gracilis, located immediately anterior to the semitendinosus tendon, from its insertion to the point that it is lost in the mass of the adductor group.
(Starkey & Ryan, 2010)
Palpation of Lateral Structures in the knee
1. Joint line - Position the knee in at least 45 degrees of flexion to locate the anterolateral joint line. Begin palpating the joint line lateral to the patellar tendon and progress posteriorly. Pain along the joint line may indicate meniscal pathology. Internally rotating the tibia makes the lateral meniscus more palpable.
2. Fibular head - Locate the fibular head below and slightly posterior to the lateral joint line. Two ropelike structures may be felt arising from the fibular head. The LCL projects off its superior portion; slightly posterior to this structure is the insertion of the biceps femoris tendon.
3. Lateral collateral ligament (LCL) - Place the knee in 90 degrees of flexion and externally rotate and abduct the hip (i.e., cross the ankle of the involved leg over the opposite leg) to make the LCL more identifiable. Because it is a separate structure from the joint capsule, the LCL is easily identified as it arises from the fibular head and courses to the lateral femoral condyle.
4. Popliteus - Palpate a small portion of the anterior popliteus tendon, posterior to the LCL just above the joint line. Provide slight resistance to knee flexion to make the tendon more prominent.
5. Biceps femoris - Flex the knee to 25 degrees and ask the patient to externally rotate the lower leg to make the biceps tendon easily palpable (note that as the tendon crosses the joint line, it may become confused with the IT band). The biceps femoris tendon inserts on the fibular head, posterior to the insertion of the LCL. Continue palpating the biceps femoris tendon to its muscular belly.
6. Iliotibial band - Palpate the IT band located anterior to the biceps femoris tendon at its insertion on Gerdy's tubercle, just lateral to the tibial tuberosity. The IT band becomes more identifiable during resisted flexion past 30 degrees. Palpate the IT band upward to the tensor fasciae latae, noting any increased sensitivity, especially as it passes over the lateral femoral condyle, possible indicating iliotibial band friction syndrome.
(Starkey & Ryan, 2010)
2. Fibular head - Locate the fibular head below and slightly posterior to the lateral joint line. Two ropelike structures may be felt arising from the fibular head. The LCL projects off its superior portion; slightly posterior to this structure is the insertion of the biceps femoris tendon.
3. Lateral collateral ligament (LCL) - Place the knee in 90 degrees of flexion and externally rotate and abduct the hip (i.e., cross the ankle of the involved leg over the opposite leg) to make the LCL more identifiable. Because it is a separate structure from the joint capsule, the LCL is easily identified as it arises from the fibular head and courses to the lateral femoral condyle.
4. Popliteus - Palpate a small portion of the anterior popliteus tendon, posterior to the LCL just above the joint line. Provide slight resistance to knee flexion to make the tendon more prominent.
5. Biceps femoris - Flex the knee to 25 degrees and ask the patient to externally rotate the lower leg to make the biceps tendon easily palpable (note that as the tendon crosses the joint line, it may become confused with the IT band). The biceps femoris tendon inserts on the fibular head, posterior to the insertion of the LCL. Continue palpating the biceps femoris tendon to its muscular belly.
6. Iliotibial band - Palpate the IT band located anterior to the biceps femoris tendon at its insertion on Gerdy's tubercle, just lateral to the tibial tuberosity. The IT band becomes more identifiable during resisted flexion past 30 degrees. Palpate the IT band upward to the tensor fasciae latae, noting any increased sensitivity, especially as it passes over the lateral femoral condyle, possible indicating iliotibial band friction syndrome.
(Starkey & Ryan, 2010)
Palpation of posterior structures in the knee
1. Popliteal fossa - Trauma to this area or edema within this space can occlude neurovascular structures, resulting in referred pain, inhibition of nerve transmission, or disruption of blood flow to or from the lower leg, possibly mimicking the signs and symptoms of thrombophlebitis. With the patient prone, palpate the popliteal fossa for the presence of a cyst, most commonly found on the medial aspect of the fossa under the medial head of the gastrocnemius and semimembranosus tendon (Baker's cyst). The cyst is usually more prominent during palpation with the knee extended. The cyst may feel firm with the knee extended and soft when the knee is flexed, Foucher's sign. Cysts may also be found laterally and are associated with the popliteus tendon.
2. Hamstring muscle group - Palpate the length of the biceps femoris on the lateral aspect of the knee and the semimembranosus/ semitendinosus muscles on the medial side of the knee to their common origin on the ischial tuberosity noting for point tenderness, spasm or defect.
3. Heads of the Gastrocnemius - Palpate the lateral and medial heads of the gastrocnemius muscle according to Figure 2 on the anatomy tab of this website.
4. Popliteal artery - Palpate the pulse associated with this artery. This pulse is most notable in the inferior portion of the popliteal fossa with the knee flexed.
(Starkey & Ryan, 2010)
2. Hamstring muscle group - Palpate the length of the biceps femoris on the lateral aspect of the knee and the semimembranosus/ semitendinosus muscles on the medial side of the knee to their common origin on the ischial tuberosity noting for point tenderness, spasm or defect.
3. Heads of the Gastrocnemius - Palpate the lateral and medial heads of the gastrocnemius muscle according to Figure 2 on the anatomy tab of this website.
4. Popliteal artery - Palpate the pulse associated with this artery. This pulse is most notable in the inferior portion of the popliteal fossa with the knee flexed.
(Starkey & Ryan, 2010)
case scenario 1:
Bilateral palpation of the knees indicates an absence of heat production, however exhibits mild point tenderness along the medial and lateral aspects of the patella as well as along the tibial condyles. Crepitus is also present amongst both knees, specifically surrounding the patella within the patellar tendon.
case scenario 2:
Bilateral palpation of the thighs proves that the left quadriceps group is much more taut than the right quadriceps group. Also, any type of palpation with the left quad is causing the athlete immense pain.