PRACTIAL 2 SPECIAL TESTS

Sweep Test

Patient Position-

• lying supine w/ knee extended

Procedure-

• Assume edema is medial

• Edema is stroked proximally and laterally

+ Test-

• reformation of edema on medial side when pressure is applied to lateral aspect

Implications-

• swelling within joint capsule, indicating possible ACL trauma or patellar dislocation

Ballotable Patella

Patient Position-

• supine w/ knee extended & quads relaxed

Procedure-

• Superiorly and inferiorly push fluid toward patella

• Press the patella down w/ a finger

+ Test-

• patella depresses, hits patellar groove, & returns back to original position

Implications-

• effusion within joint capsule

Anterior Drawer

Patient Position-

• lying supine w/ hips flexed to 45* and knee to 90*

Examiner Position-

• Sit on patient foot (of involved leg)

• Grasp tibia just blow joint line w/ thumbs places alone joint line on sides of patellar tendon

Procedure-

• tibia is drawn anteriorly

+ Test-

• Increased amount of anterior tibial translation

Implications-

• sprain of anteriomedial bundle of ACL or complete tear of ACL

Lachman’s Test

Patient Position-

• Lying supine w/ knee passively flexed to 25*

Examiner Position-

• One hand grasps tibia around level of tibial tuberosity

• Other hand grasps femur just above level of condyles

Procedure-

• While supporting weight of leg and knee still flexed, tibia is drawn anteriorly

• Apply slight posterior pressure to femur for stabilization

+ Test-

• Increased amount of anterior tibial translation

Implications-

• Sprain of ACL

Alternate Lachman’s

Patient Position-

• Prone w/ knee passively flexed to 30*

Examiner Position-

• At leg of patient to support the ankle

• Palpate anterior joint line on either side of patellar tendon

Procedure-

• Downward pressure placed on proximal portion of posterior tibia

+ Test-

• Excessive anterior translation

Implications-

• IF ALSO + LACHMAN’S:

  • + = sprain of ACL

  • - = sprain of PCL

Lever Sign

Patient Position-

• Supine w/ knee extended

Examiner Position-

• Standing next to patient w/ fist under tibia (approx. 1/3 distance from joint line to malleoli)

• Opposite hand on distal quad muscle, just proximal to patella

Procedure-

• Apply downward force to quads

+ Test-

• Heel remains flat on table

Implications-

• ACL rupture

Posterior Drawer

Patient Position-

• Supine w/ hips flexed to 45* & knee 90*

Examiner Position-

• Sitting on foot of involved leg

• Patient’s tibia stabilized in neutral position

Procedure-

• Grasp tibia just below joint line w/ thumbs placed along joint line on either side of patellar tendon

• Proximal tibia is pushed posteriorly

+ Test-

• Increased amount of posterior tibial translation

Implications-

• Sprain of PCL

Godfrey’s Test

Patient Position-

• Supine w/ knees extended & legs together

Examiner Position-

• Standing next to patient

Procedure-

• Lift patient’s lower legs & hold parallel to table w/ knees flexed to 90*

• Observe levels of tibial tuberosities

+ Test-

• Unilateral posterior displacement of tibial tuberosity

Implications-

• Sprain of PCL

Quadriceps Active Test

Patient Position-

• Supine w/ knees flexed to 90*

Examiner Position-

• Side of patient

• One hand stabilized distal tibia, other stabilized distal femur

Procedure-

• While resisting knee extension, patient is asked to slide foot forward by contracting quads

• Observe any anterior translation of tibia

+ Test-

• Anterior translation of tibia on femur

Implications-

• Grade II or III PCL sprain

Valgus Stress Test

Patient Position-

• Supine w/ involved leg close to edge of table

Examiner Position-

• Standing lateral to support involved limb

• One hand supports medial portion of distal tibia, other grasps knee along lateral joint line

• To isolate MCL, knee is flexed to 25*

• For entire medial joint capsule, knee is kept in complete extension

Procedure-

• Valgus (Medial) force is applied to knee while distal tibia is moved laterally

+ Test-

• Increased laxity, decreased quality of end-point, & pain compared to uninvolved

Implications-

• 25* of flexion = Sprain of MCL

• Complete extension = Sprain of MCL, medial joint capsule, and possibly cruciate ligaments

Varus Stress Test

Patient Position-

• Supine w/ involved leg close to edge of table

Examiner Position-

• Sitting on table

• One hand supports lateral portion of distal tibia, other grasps knee along medial joint line

• To isolate LCL, knee is flexed to 25*

• For entire lateral joint capsule, knee is kept in complete extension

Procedure-

• Varus (Lateral) force is applied to knee while distal tibia is moved inward

+ Test-

• Increased laxity, decreased quality of end-point, & pain compared to uninvolved

Implications-

• 25* of flexion = Sprain of LCL

• Complete extension = Sprain of LCL, lateral joint capsule, and possibly cruciate ligaments & possible rotary instability of joint

Tibiofibular Translation Test

Patient Position-

• Supine w/ knees passively flexed to approx 90*

Examiner Position-

• Standing lateral to involved side

Procedure-

• One hand stabilized tibia, other grasps fibular head

• Attempt to displace fibular head anteriorly then posteriorly

+ Test-

• Any perceived movement of fibula on tibia compared w/ uninvolved side

• Pain during testing

Implications-

• Anterior fibular shift = damage to proximal posterior tibiofibular ligament

• Posterior fibular shift = instability of anterior tibiofibular ligament of proximal tibiofibular syndesmosis

Slocum Drawer

Patient Position-

• Supine w/ knee flexed to 90*

Examiner Position-

• Sitting on patients foot

• Tibia is internally rotated to 25*

  • Tests anterolateral capsule instability

• Tibia is externally rotated 15*

  • Tests anteromedial capsule instability

Procedure-

• Tibia is drawn anteriorly

+ Test-

• Increased amount of anterior tibial translation compared w/ opposite side

• Lack of firm end-point

Implications-

• Anterolateral instability test = damage to ACL, anterolateral capsule, LCL, IT band, popliteus tendon, posterolateral capsule

• Anteromedial instability test = damage to MCL, anteromedial capsule, ACL, posteromedial capsule

Posterolateral/Posteromedial Drawer Test

Patient Position-

• Supine w/ knees flexed to 80*

  • Tibia rotated externally 15*

    • Posterolateral test

  • Tibia rotated internally 15*

    • Posteromedial test

Examiner Position-

• Sitting on foot of limb being tested

• Hands grasp proximal tibia

Procedure-

• Posteriro force applied to proximal tibia

+ Test-

• Increased external rotation of lateral (posterolateral) or medial (posteriomedial) tibial condyle relative to uninvolved side

Implications-

• Posterolateral test = trauma to posterolateral corner, PCL, possible posterolateral rotary instability

• Posteromedial tet = PCL tear, oblique ligament, MCL, posteromedial capsule, semimembranosus

External Rotation Recurvatum Test

Patient Position-

• Lying supine

Examiner Position-

• Standing at patient’s feet grasping the great toes/distal midfoot

Procedure-

• Lift patient’s legs approx 12 inches off table

• Observe bilateral alignment of both knees

+ Test-

• Marked difference in hyperextension, external femoral rotation, & varus alignment between knees

Implications-

• Posterolateral corner trauma, PCL sprain, posterolateral rotary instability

Crossover Test

Patient Position-

• Standing w/ weight on involved limb

Examiner Position-

• Standing in front of patient

Procedure-

• ALRI = patient steps across and in front w/ uninvolved leg, rotating torso in direction of movement

• AMRI = patient steps across and behind w/ uninvolved leg, rotating torso in direction of movement

+ Test-

• Patient reports pain, instability, or apprehension

Implications-

• ALRI = instability of lateral capsular restraints

• AMRI = instability of medial capsular restraints

Lateral Pivot Shift Test

Patient Position-

• Lying supine w/ hips passively flexed to 30*

Examiner Position-

• Standing lateral to patient

• Distal lower leg and/or ankle is grasped maintaining 20* internal tibial rotation

• Knee is allowed to sag into complete extension

• Opposite hand grasps lateral portion of leg at level of superior tibiofemoral joint, increasing force of internal rotation

Procedure-

• While maintaining internal rotation, valgus force is applied to knee while its slowly flexed

+ Test-

• Tibia’s position on femur is reduced as leg is flexed into 30-40*

• During extension, anterior subluxation is felt

Implications-

• Tear of ACL, posterolateral capsule, arcute ligament complex, or IT band

Reverse Pivot Shift Test

Patient Position-

• Supine

Examiner Position-

• Standing to side of uninvolved leg

Procedure-

• Examiner flexed knee and externally rotated tibia of involved leg

• Patient’s knee is passively extended while valgus stress is applied to knee

+ Test-

• Clunk of tibia on femur

Implications-

• Posterolateral rotary instability and/or trauma to posterolateral corners

Dynamic Posterior Shift Test

Patient Position-

• Supine

Examiner Position-

• Standing on side being tested

Procedure-

• Examiner passively flexed patient’s hip and knee to 90*

• Knee is then passively extended

+ Test-

• Clunk or jerk as knee nears full extension, representing subluxated tibia reducing on femur

Implications-

• Posterolateral instability

Slocum Anterolateral Rotary Instability

Patient Position-

• Lying on uninvolved side w/ uninvolved leg flexed at hip and knee

• Involved hip externally rotated

• Involved leg extended w/ medial aspect of foot resting against table for stability

Examiner Position-

• Standing behind patient, grasping knee at distal aspect of femur & proximal fibula

Procedure-

• Valgus force applied on knee, causing it to move into 30-50* of flexion

+ Test-

• Appreciable “clunk” or instability as lateral tibial plateau subluxates

• Pain or instability is reported

Implications-

• Tear of ACL, LCL, anterolateral capsule, arcuate ligament comples, biceps femoris tendon and/or IT band

Flexion Reduction Drawer Test

Patient Position-

• Lying supine, examiner lifts calf and ankle so knee is flexed to approx. 25*

Examiner Position-

• Standing lateral & distal to involved knee

Procedure-

• Tibia is depressed posteriorly to femur

• Valgus stress and axial compression along tibial shaft are applied as knee is slowly flexed

+ Test-

• Femur relocating itself on tibia by moving anteriorly & internally rotating on tibia

Implications-

• Tear of ACL, LCL, anterolateral capsule, bicep femoris tendon and/or IT band

External Rotation Test

Patient Position-

• Prone or supine

Examiner Position-

• Standing at patient’s feet

Procedure-

• Knee is flexed to 30*

• Using medial border of foot as point of reference, examiner forcefully externally rotates patients lower leg

• Position of ER of foot relative to femur is assessed and compared w/ opposite leg

• Knee is then flexed to 90* and test is repeated

+ Test-

• Increase of ER greater than 10* compared with opposite side

Implications-

• Difference at 30* but not 90* = injury isolated to arcuate ligament complex & posterlateral structures

• Difference at 30* & 90* = trauma to PCL, posterolateral knee structures, & arcuate ligament complex

• Difference at 90* but not 30* = isolated PCL sprain

McMurray’s Test

Patient Position-

• Lying supine

Examiner Position-

• Standing lateral & distal to involved knee

• One hand supporting lower leg while thumb & index finger of opposite hand positioned in anteromedial & anterolateral joint line on sides of patellar tendon

Procedure-

• Pass 1: While tibia is maintained in neutral position, valgus stress is applied while knee is flexed though available ROM

  • Varus stress is applied as knee is returned to full extension

• Pass 2: Examiner internally rotates tibia & applies valgus stress while knee is flexed though available ROM

  • Varus stress applied as knee is extended

• Pass 3: With tibia externally rotated, examiner applies valgus stress while knee is flexed through available ROM

  • Varus stress applied as knee is extended

+ Test-

• Popping, clicking, or locking of knee

• Pain emanating from menisci

• Sensation similar to that experienced during ambulation

Implications-

• Meniscal tear on side of reported symptoms

Appley’s Compression & Distraction Test

Patient Position-

• Lying prone w/ knee flexed to 90*

Examiner Position-

• Standing lateral to involved side

Procedure-

• Compression test: clinician applies pressure to plantar aspect of heel, applying an axial load to tibia while also internally & externally rotating tibia

• Distraction test: clinician grasps lower leg & stabilizes knee proximal to femoral condyles. Tibia is distracted away from femur while internally & externally rotating tibia

+ Test-

• Pain experienced during compression test that is reduced or eliminated during distraction

Implications-

• Meniscal tear

Thessaly Test

Patient Position-

• Standing flatfooted on involved leg w/ knee of opposite leg flexed to 45*

Examiner Position-

• Standing in front of patient supporting patient’s arms

Procedure-

• Test uninvolved limb first

  • Bout 1

    • Patient flexed knee to 5* & rotates body to internally & externally rotate femur on tibia

  • Bout 2

    • Patient flexes knee to 20* & rotates body to internally & externally rotate femur on tibia

+ Test-

• Joint line discomfort, locking, or catching

Implications-

• Lesion of medial or lateral meniscus

Wilson’s Test

Patient Position-

• Sitting w/ knee flexed to 90*

Examiner Position-

• In front of patient to observe any reactions secondary to pain

Procedure-

• Patient actively extends knee while maintaining tibia in internal rotation

  • Patient is told to stop motion and hold knee in position in which pain is experienced

• If pain is experienced, patient is instructed to externally rotate tibia while knee is at present point of flexion

+ Test-

• Pain experienced during extension w/ internal tibial rotation that is relieved by externally rotating tibia

Implications-

• OCD os osteochondritis dissecans on intercondylar area of medial femoral condyle

Q angle measurement w/ knee extended

Patient Position-

• Lying supine w/ knee fully extended

Examiner Position-

• Standing on side of limb to be measured

Procedure-

• Identify & mark ASIS, midpoint of patella, & tibial tuberosity

• Place goniometer w/ axis over patella midpoint, stationary arm towards ASIS, and moving arm towards tibial tuberosity

+ Test-

• Q angle greater than 13* for men & 18* for women

Implications-

• Increased lateral forces leading to a laterally tracking patella

Q angle measurement w/ knee flexed

Patient Position-

• Sitting w/ legs over edge of table w/ knees flexed to 90*

Examiner Position-

• Standing on side of limb to be measured

Procedure-

• Identify & mark ASIS, midpoint of patella, & tibial tuberosity

• Place goniometer w/ axis over patella midpoint, stationary arm towards ASIS, and moving arm towards tibial tuberosity

+ Test-

• Q angle greater than 8*

Implications-

• Increased lateral tracking during knee flexion, predisposing patient to lateral patellar subluxation or dislocations

Clarke’s Sign

Patient Position-

• Lying supine w/ knees extended

Examiner Position-

• Standing lateral to limb being evaluated

• One hand placed proximal to superior patellar pole, applying a gentle downward pressure

Procedure-

• Patient is asking to contract quads while pressure is maintained on patellar, pushing it into femoral trochlea

+ Test-

• Patient experiences patellofemoral pain & inability to hold contraction

Implications-

• Possibly chondromalacia patella

• Unreliable test, producing false-positive results

Patella Tilt Test

Patient Position-

• Supine w/ knee extended and femoral condyles parallel to table

Examiner Position-

• Standing lateral to patient

Procedure-

• Grasp patella w/ forefinger & thumb, elevating lateral borders & depressing medial border

+ Test-

• Normal result = lateral border raising between 0-15*

• More than 15* = hypermobile lateral tilt

• Less than 0* = hypomobile lateral tilt

Implications-

• Less than 0* = tightness of lateral restraints and often occur in presence of hypomobile medial glide

• More than 15* = may predispose individual to anterior knee pain

Medial & Lateral Patellar Glide

Patient Position-

• Supine w/ bolster placed under knee so it’s flexed to 30*

Examiner Position-

• Standing lateral to patient

Procedure-

• MEDIAL GLIDE:

  • Move patella medially, placing stress on lateral retinaculum & other soft tissue restraints

• LATERAL GLIDE:

  • Move patella laterally, placing stress on medial retinaculum, VMO, & medial capsule

+ Test-

• MEDIAL GLIDE;

  • Patella should glide 1 or 2 quadrants medially

    • 1 or less quadrant = hypomobile

    • More than 2 quadrants = hypermobile

• LATERAL GLIDE:

  • Normal is .5-2.0 quadrants

    • Less than that is hypomobile

    • Greater than 2 is hypermobile

Implications-

• MEDIAL GLIDE:

  • Hypomobile = tightness of lateral retinaculum or IT band

  • Hypermobile = laxity of lateral restraints

• LATERAL GLIDE:

  • Hypomobile = tightness of medial restraints, specifically medial patellofemoral ligament

  • Hypermobile = laxity of medial restraints
    

Apprehension Test

Patient Position-

• Lying supine w/ knee extended

Examiner Position-

• Standing lateral to involved side

Procedure-

• Examiner attempts to move patella as far laterally as possible, taking care not to actually dislocate it

+ Test-

• Forcible contraction of quads by patient to guard against dislocation of patella

• Patient may also demonstrate apprehension verbally or though facial expressions

Implications-

• Laxity of medial patella retinaculum, predisposing patient to patella subluxations or dislocations

Test for Medial Synovial Plica

Patient Position-

• Lying supine w/ knee flexed or w/ patient seated

Examiner Position-

• Standing on side being tested

Procedure-

• W/ knee flexed to 90* & tibia internally rotated, examiner passively moves patella medially while palpating anteromedial capsule

• Knee is then extended & flexed from 90-0* while tibia is internally rotated

+ Test-

• Reproduction of symptoms is described by patient

• Clinician may feel the plica as it crosses the medial femoral condyle, especially in range of 60-45* of flexion

Implications-

• Symptomatic medial synovial plica

Stutter Test for Medial Synovial Plica

Patient Position-

• Sitting w/ knee flexed over edge of table

Examiner Position-

• Standing lateral to involved side, lightly cupping one hand over patella, being careful not to compress articular surfaces

Procedure-

• Patient slowly extends knee

+ Test-

• Irregular motion or stuttering between 40-60* as plica passes over medial condyle

Implications-

• Medial synovial plica

Clinical Determination of Angle of Torsion

Patient Position-

• Prone w/ knee of leg being tested flexed to 90*

Examiner Position-

• Examiner 1: on contralateral side to the being test, one hand palpated greater trochanter & other manipulated lower extremity

• Examiner 2: holding goniometer distal to flexed knee w/ stationary arm perpendicular to tabletop

Procedure-

• Examiner 1: internally rotates femur inward & outward until greater trochanter is maximally prominent

• Examiner 2: measures angle formed by lower leg

+ Test-

• Angles less than 15* = retroversion

• Angles greater than 20* = anteversion

Implications-

• As described in + test

Noble’s Compression Test

Patient Position-

• Lying supine w/ knee flexed

Examiner Position-

• Standing lateral to side being tested

• Knees supported above joint line w/ thumb over or just superior to lateral femoral condyle

• Opposite hand controlling lower leg

Procedure-

• While applying pressure over lateral femoral condyle, knee is passively extended & flexed

+ Test-

• Pain under thumb, most commonly as knee is approaching 30*

Implications-

• Inflammation of IT band, its associated burs, or inflammation of lateral femoral condyle

Ober’s Test

Patient Position-

• Lying on side opposite that is being testes w/ knee in flexion

• Opposite leg may be flexed to 90* at knee & hip to stabilize torso & pelvis

Examiner Position-

• Standing behind patient, grasp leg along medial aspect of proximal tibia

Procedure-

• Examiner abducts & extends hip to allow TFL to clear greater trochanter

• Hip is the allowed to passively adduct to table w/ knee kept straight

+ Test-

• Leg is unable to adduct past parallel

Implications-

• Tightness of IT band, predisposing individual to IT band friction syndrome and/or lateral patellar malalignment

Thomas Test

Patient Position-

• Lying supine w/ knees bent at end of table

Examiner Position-

• Standing behind patient

Procedure-

• Examiner placed one hand between lumber lordotic curve & tabletop

• One leg is passively flexed to patient’s chest, allowing knee to flex during movement

• Opposite leg (leg being tested) rests flat on table

+ Test-

• Lower leg moves into extension

• Involved leg rises off table

Implications-

• Tightness of rectus femoris

• Tightness of iliopsoas muscle group

Ely’s Test

Patient Position-

• Lying prone

Examiner Position-

• Standing beside patient

Procedure-

• Knee is passively flexed toward patient’s buttocks

+ Test-

• Hip on side being tested flexed, causing it to rise from table

Implications-

• Tightness of rectus femoris

Trendelenburg’s Test

Patient Position-

• Standing w/ weight evenly distributed between both feet

• Patients shorts are lowered to point at which iliac crest or PSIS are visible

Examiner Position-

• Standing, sitting, or kneeling behind patient

Procedure-

• Patient lifts leg opposite side being tested

+ Test-

• Pelvis lowers on the non-weight bearing side

Implications-

• Insufficiency of gluteus medius to support torso in an erect position, indicating weakness in muscle or decreased innervation

Hip Scouring Test

Patient Position-

• Supine

Examiner Position-

• At side of patient fully flexing patient’s hip & knee

Procedure-

• Examiner applies pressure downward along shaft of femur to compress joint surfaces

• Femur internally & externally rotated w/ hip in multiple angles of flexion

+ Test-

• Pain described or symptoms in hips reproduced

Implications-

• Possible defect in articular cartilage of femur or acetabulum

• Possible labral tear

Femoral Nerve Stretch Test

Patient Position-

• Prone w/ pillow under abdomen or side lying

Examiner Position-

• At side of patient

Procedure-

• Examiner passively extends hip while keeping patient’s knee flexed to 90*

+ Test-

• Pain is elicited in anterior & lateral thigh

Implications-

• Nerve root impingement at L2, L3, L4 level

Fabere Test

Patient Position-

• Supine w/ foot of involved side crossed over opposite thigh

Examiner Position-

• As side to be tested w/ one hand on opposite ASIS and other on medial aspect of flexed knee

Procedure-

• Extremity is allowed to rest in full external rotation following by the examiner’s applying overpressure at the knee & ASIS

+ Test-

• Pain in sacroiliac joint or hip

Implications-

• Pain in inguinal area anterior to hip = hip pathology

• Pain during application of overpressure in SI area = SI joint pathology

Gaenslen’s Test

Patient Position-

• Supine, lying close to side of table

Examiner Position-

• Standing at side of patient

Procedure-

• Examiner slides patient close to edge of table

• Patient pulls far knee up to chest, near leg is allowed to hang over the edge of table

• While stabilizing patient, examiner applies pressure to the near leg, forcing it into hyperextension

+ Test-

• Lumbar spine should not go into extension during test

• Pain in SI region

Implications-

• SI joint dysfunction

Long Sit Test

Patient Position-

• Supine w/ heels off table

Examiner Position-

• Holding feet w/ thumbs placed over medial malleoli

Procedure-

• Examiner provides slight traction on legs while patient performs glute bridges (3x)

• Patient then move from supine into a long sit position

• Examiner must pay close attention to the malleoli at all times throughout test

• Test is done actively if possible, without assistance of upper extremities

+ Test-

• Movement of medial malleoli is observed

• UNINVOLVED LEG: LONGER —> SHORTER

  • Anterior rotation of ilium on that side

• INVOLVED LEG: SHORTER —> LONGER

  • Posterior rotation of ilium on sacrum

Implications-

• Rotation as noted above