MUSCULOSKELETAL EXAMINATON OF THE KNEE (P2: special tests)

Tests for ligamentous stability

• Anterior Drawer Test

• Jerk Test of Hughston

• Lachman Test

• Lelli Test

• Pivot Shift Test

• Posterior Drawer Sign

• Posterior Sag Sign

• Reverse Lachman Test

• Slocum Test

• Valgus Stress Test

• Varus Stress Test

Identify

Anterior Drawers Test:

• Pt knees flexed to 90^o, hip flexed to 45^o (ACL is parallel to tibial plateau), pt foot is held to the table (neutral position) 

• PT ensures HS mm are relaxed then draw tibia forward on the femur 

• (+) if tibia moves more than 6 mm on the femur

• Structures injured in a (+) Anterior Drawers Test:

Structures injured to some degree: 

1. Anterior cruciate ligament (especially the anteromedial bundle)

2. Posterolateral capsule

3. Posteromedial capsule

4. Medial collateral ligament (deep fibers)

5. Iliotibial band

6. Posterior oblique ligament

7. Arcuate-popliteus complex

Identify

90-90 Anterior Drawer

• Pt in supine with hips and knees flexed to 90^o 

• PT places hand around the tibia and applies sufficient force to slowly lift the pt’s buttocks off the table 

• (+) excessive anterior translation of tibia

Sign shown when there is an audible snap or palpable jerk when doing the ant. drawers test

Finochietto Jumping Sign

Identify

Sitting Anterior Drawer Test

• Pt short-sitting on bed (posterior sag is eliminated d/t gravity) 

• PT places hands with standardized test and draws tibia forward then backward (anterior and posterior drawer) 

• (+) excessive tibial plateau movement 

Identify

Jerk Test of Hughston

• Pt in supine with hip flexed 90 degs and abducted 45 degs and slight IR (same with pivot shift manuever) 

• Leg is extended, maintain IR and valgus stress

• (+) if at 20-30 degs flexion tibia shifts forward cause a subluxation of tibial plateau with jerk; ALRI

Identify

Lachman Test

• AKA Ritchie, Trillat Test, Gold standard for ACL Tests

• Pt supine then PT flexes knee between 30 degs to full extension

• Stabilize the femur ,then apply force pulling the tibia anteriorly (apply force in posteriomedial aspect) 

• (+) if mushy or soft endfeel and disappearance of infrapatellar slope

(+) Lachman test affected structures:

1. Anterior cruciate ligament (especially the posterolateral bundle) 

2. Posterior oblique ligament 

3. Arcuate-popliteus complex

Modifications of Lachman:

• Pt sitting dangling then rest foot on PT thigh so the knee is flexed to 30 degs

•  PT stabilize the thigh then pulls tibia forward with other hand

• (+) if excessive forward motion

Modification 1

Modifications of Lachman:

• Pt in supine

• PT looks at knee eye level 

• PT holds femur then pulls tibia upward

Modification 5

Modifications of Lachman:

• Pt in supine with hip abducted with knee flexed to 25 degs

• PT stabilize the thigh then holds the foot between the knees 

• Apply anterior force to tibia 

Modification 3

drop leg lachman test

Modifications of Lachman:

• Pt in supine with knee on top of PT forearm so knee is flexed 30 degs

• Pt is asked to extend knee, PT watches for anterior displacement of tibia

Modification 7:

no touch lacman test

Modifications of Lachman:

• Pt in supine with knee on top of PT knee 

• PT stabilize thigh then apply anterior force on the tibia

Modification 2

stable lachman test FOR PT c small hands

Modifications of Lachman:

• Basically modification 7 but PT stabilizes the foot to increase pull of quads 

• Make sure no posterior sag prior to doing test

Modification 8:

maximum quads test

Modifications of Lachman:

• Pt in prone with leg in between PT thorax and arm 

• Knee is flexed around 30 degs

• Stabilize femur then push tibia downard

HARD TO ASSESS ENDFEEL

Modification 6:

prone lachman test

Modifications of Lachman:

• Pt in supine with leg in between thorax and arm of PT

• Knee is flexed to 30 degs

• Put both hands on tibia and apply anterior drawer

Modification 4:

Grading of Lacman with stress radiograph:

• grade 1 =

• grade 2 =

• grade 3 =

• grade 4 =

Grading of Lacman with stress radiograph:

• grade 1 = 3-6 mm

• grade 2 = 6-9 mm

• grade 3 =10-16 mm

• grade 4 =16-20 mm

Identify

Lelli Test

• Pt in supine knee extended

• PT place fist on proximal ⅓ of calf then apply pressure on distal ⅓ of quads 

• (+) if heel does not lift of bed

• (-) if heel lifts off (first pic) 

cannot be used in isolation to dx ACL tear

Identify

Pivot Shift Test

• Pt sits with foot on floor with knee flexed 80-90 degs 

• Pt has to isom contract quads while PT stabilize foot 

• (+) if anterolateral subluxation of lateral tibia plateau

  • indicative of ALRI

Identify

Lateral Pivot Shift Maneuver

• Pt in supine with hip flexed and abducted 30 degs and slight IR 

• PT stabilizes foot and holds knee (fibula) with other hand 

• PT applies anterior force as you put knee into extension 

• Test for ALRI and ACL tears (3rd degree)

  • Dynamic Subluxation

Posterior Drawer Sign

• Same position with anterior drawer test 

• PT pushes tibia postreriorly to femur 

• (+) if excessive tibial translation

Structures injured if (+) or Posterior Sag sign is (+) 

1. Posterior cruciate ligament

2. Arcuate-popliteus complex

3. Posterior oblique ligament

4. Anterior cruciate ligament

Identify

Gravity Drawer Test

• Posterior Sag Sign

• Pt in supine with hip flexed to 45 degs and knee flexes to 90 degs = tibia will sag back or “drops back” 

• (+) PCL tear

If medial tibial plateau does not extends 1cm anteriorly during 90 degs knee flexion this sign is present d/t torn meniscus

(+) Step-off test or Thumb sign

Structures that may be involved with a (+) Posterior Sag Sign:

1. Posterior cruciate ligament

2. Arcuate-popliteus complex 

3. Posterior oblique ligament 

4. Anterior cruciate ligament

Idenitfy

Reverse Lachman Test

• Pt prone with knee flexed to 30 degs then stabilize thigh

• Pt then pulls tibia superiorly then check endfeel and movement 

• (+) PCL tear if excessive translation 

Posterior drawer test better since greatest displacement is at 90 degs knee flexion

Identify

Slocum Test

For ALRI

• Pt in supine flex knee to 80-90 degs and hip flexed to 45 degs

• IR foot to 30 degs then draw tibia forward

• If (+) most of movement comes from lateral side of knee also indicates ALRI

For AMRI

• Lemaire’s T drawer Test 

• Foot is placed in 15^o of ER, tibia is drawn forward by PT 

• (+) if movement occurs primarily on the medial side of the knee

Possible Affected structures (+) Slocum test (for ALRI):

Possible affected structures:

1. Anterior cruciate ligament 

2. Posterolateral capsule 

3. Arcuate-popliteus complex 

4. Lateral collateral ligament

5. Posterior cruciate ligament

6. Iliotibial band

Possible Affected structures (+) Slocum test (for AMRI):

Possible affected structures:

1. Medial collateral ligament 

2. Posterior oblique ligament

3. Posteromedial capsule

4. Anterior cruciate ligament

Idenify

Valgus Stress Test

• Pt in supine 

• Apply valgus stress on knee (push it medially) with stabilized ankle in ER 

• From flexion, knee is slightly flexed (20-30^o) = “unlocked” 

• (+) excessive ROM

Identify

Hughston’s Valgus Test 

• Same position as valgus stress test

• But apply valgus stress by holding the big toe, allow natural rotation of tibia 

• (+) excessive ROM

• For medial instability

Injury in the following If valgus stress test is (+) in extension:

1. Medial collateral ligament (superficial and deep fibers)

2. Posterior oblique ligament

3. Posteromedial capsule

4. Anterior cruciate ligament

5. Posterior cruciate ligament

6. Medial quadriceps expansion

7. Semimembranosus muscle

If (+) valgus stress test in 20-30 deg flexion:

1. Medial collateral ligament  

2. Posterior oblique ligament 

3. Posterior cruciate ligament 

4. Posteromedial capsule

Identify

Varus stress test

• Pt in supine 

• PT apply varus stress

• Done in 30 deg knee flexion and full extension

Where do you apply varus stress in the Hughston’s varus test?

Apply varus stress on the 4th and 5th toes 

Injury in the following structures if (+) Varus stress test in extension:

1. Fibular or lateral collateral ligament 

2. Posterolateral capsule 

3. Arcuate-popliteus complex 

4. Biceps femoris tendon 

5. Posterior cruciate ligament 

6. Anterior cruciate ligament 

7. Lateral gastrocnemius muscle 

8. Iliotibial band

Injury in the following structures if (+) Varus stress test in  20-30 degs flexion with ER of tibia :

1. Lateral collateral ligament 

2. Posterolateral capsule 

3. Arcuate-popliteus complex 

4. Iliotibial band 

5. Biceps femoris tendon

Tests for swelling

• Brush Test

• Patellar Tap Test

Identify

Brush, Stroke, or Bulge Test

AKA wipe test

For minimal effusion 

• Start at the jt line on the medial side of patella then stroke proximally toward hip for 2-3 times (suprapatellar pouch) 

• Use the other hand to stroke the lateral jt line of patella downward

there will be a bulge of fluid around 4-8 ml in 2 secs

Idenitfy

Patellar Tap Test

“Ballotable patella” 

• Pt positions knee to position of discomfort (flex or ext) 

• PT applies slight pressure or taps the patella

• (+) if floating of patella (aka Dancing Patella sign)

Modification: 

• PT applies thumb and forefinger of one hand lightly on both sides of patella 

• Using other hand, PT then strokes down on the suprapatellar pouch

• (+) separation of thumb and forefinger 

Detects up to 40-50mL of swelling in the knee

Tests for Plica lesions

• Hughston’s Plica Test

• Plica “Stutter” Test

Identify

Hughston’s Plica Test

• Pt in supine while PT flexes knee and IR tibia while pushing patella medially and palpating the medial condyle 

• Passively flex and extend knee

• (+) if popping

What test is described?

• Pt on the edge of table with knee flexed to 90 degs while palpating patella 

• Pt has to extend the knee slowly  

• (+) if patella stutters or jumps somewhere between 60^o and 45^o 

  test is only effective when there is no swelling

Plica “Stutter” Test

Tests for Meniscal Injuries

• Apley’s Test

• Bounce Home Test

• Childress’ sign

• Ege’s Test

• McMurray Test

• Thessaly Test

Identify

Apley’s Test

• Pt in prone with knee flexed to 90 degs

• Anchor pt’s thigh using PT knee

• Distract the tibia from the knee jt then apply IR and ER

• Next do the same thing except using compression instead of distraction

• If IR and ER more painful with distraction or increased rotation to one side = (+) ligemental affectation

• If IR and ER more painful with compression or decreased rotation = (+) meniscal affectation

  
  

Identify

Bounce Home Test

• Pt in supine, then PT cups foot

• Pt’s knee is flexed and then passively extended 

• Note for incomplete ROM and springy block end feel

• If something is blocking full extension = most likely torn meniscus (springy block)

Identify

Childress Test

AKA Squat and Duck Walk test

• Ask pt to squat then walk or waddle forward in the squatting position 

• (+) if pain in joint line or painful clicking = posterior horn lesion of meniscus

Idenitfy

McMurray’s Test

• Pt in supine with knee maximally flexed (heel to ass)

• PT IR tibia then extends knee to asses lateral meniscus

• PT ER tibia then extends knee to assess medial lemniscus 

• if accompanied by pain and snapping = indicative of loose bodies

Identify

Ege’s Test

Basically a WB McMurray’s test

• Pt stands with feet 30-40cm (11-15 inches) apart

Testing for medial meniscus 

• Pt ER tibia then squats then slowly stand up

Testing for lat meniscus 

• Pt IR tibia then squats then slowly stand up

• (+) if pain along jt. line and clicking sounds 

not accurate in acute cases <6 wks

squatting with IR is difficult even in healthy individuals

Identify

Thessaly’s Test

• Pt stands on one leg, PT can help balance 

• Pt flexes knee 5 degs (then 20 deg) then IR and ER femur on tibia 3 times

• (+) if jt. line discomfort; May have locking or catching 

Contraindicated for ACL injury

Tests for Patellar Affectation:

• Clarke’s Sign

• Eccentric Step Test

• Fairbank’s Apprehension test

• Noble Compression Test

• Step up Test

• Waldron Test

Identify

Clarke’s Sign or  Patellar Grind Test

For articulation problem between the patella and femoral condyles 

• Pt in supine knees extended 

• PT presses down on superior pole of patella using web of hand  

• Push down on the patella while pt contracts quads 

• (+) if pt cant maintain contraction or pain on patella

  • better if test is repeated in many different ROMS of knee flexion (30, 60, 90) and increasing pressure

Identify

Eccentric Step Test or Lateral Step Down Test

• Pt stands on a 15 cm-high step with hands on hip (6 inches) 

• Pt steps down slowly using the injured leg first, while PT watches

• (+) if pain

Eccentric Step Test or Lateral Step Down Test scoring:

• Score range for good quality of movement?

• Score range for medium quality of movement?

• Score range for poor movement?

Eccentric Step Test or Lateral Step Down Test scoring:

• 0-1

• 2-3

• 4+

Identify

Fairbank’s Apprehension Test

• Pt in supine with knees flexed to 30 degs, quads relaxed 

• PT then pushes patella laterally and distally

• (+) if pt feels apprehension seen by the contraction of quads

Identify

Noble Compression Test

For checking if pt has ITB friction syndrome near knee (chronic inflammation of ITB near insertion/ femoral condyles)

• Pt in supine with knee flexed to 90 degs with hip flexion 

• PT extends the knee while applying pressure on lateral femoral condyle 

• (+) if at 30 degs knee flexion, pt feels pain on lateral femoral condyle; Same pain pt feels when running

Identify

Step up Test

• Pt stands beside stool 25 cm high

• Pt is instructed to step up laterally using good leg then the injured leg

• (+) may indicate patellofemoral arthralgia, weak quads, or inability to stabilize pelvis 

Identify

Waldron Test

• Palpate patella while pt performs slow deep knee bends (squats)  

• PT has note for crepitus throughout ROM

• (+) if pain and crepitus in ROM

Tests for Muscle Dysfunction:

• 90–90 straight leg raise test

• Trendelenburg test

• Ely’s Test

• Ober’s Test

• Thomas Test

• Noble Compression Test

• Adductor Squeeze Test

• Hip Lag Sign

• Phelps’ Test

• Piriformis Test

• Sign of the Buttock

• Tripod Sign

(read hip special tests we finished dis alr)

THAT FEELING WHEN KNEE SURGERY IS TOMORROW