MSK Unit 3 Special Tests

Valgus / Varus Stress Tests

Purpose

• Valgus stress: medial structures/MCL

• Varus stress: lateral structures/LCL

• 30° only = isolated collateral-ligament injury

• 0° & 30° = more global ligamentous instability

How to perform

1. pt supine with 0° knee extension

2. Apply a valgus force to assess the medial structures

3. Apply a varus force to assess the lateral structures

4. Repeat both tests w/ 30° knee flexion

5. Compare pain, gapping, and end feel with the opposite knee

Positive test

• Pain and/or excessive joint-line gapping

• Increased laxity or a softer end feel compared to non-test leg

Interpretation

• Positive at 30° only: MCL or LCL only

  • Valgus = isolated MCL injury

  • Varus = isolated LCL injury

• Positive at both 0° and 30°: global ligament injury

  • Collateral-ligament injury (MCL/LCL) plus involvement of additional stabilizers, such as the ACL, PCL, or joint capsule

  • MCL/LCL injury + ACL, PCL, and/or joint capsule involvement

Lachman Test

LIGAMENTOUS STABILITY (anterior instability)

Purpose

• ACL integrity (gold-standard ACL special test)

How to perform

1. pt supine w/ knee between full extension and <30° flexion

2. Stabilize femur

3. Grasp the proximal tibia, placing the thumb near the tibial plateau or joint line

4. Translate the tibia anteriorly while keeping the femur stable

5. Feel the amount of translation and the end feel

Optional:

• If the leg is difficult to hold, support the thigh with a bolster or the clinician’s knee

Positive test

• Excessive anterior tibial translation

• Soft end feel

Clinical pearl: Keep the heel from digging into the table and make sure the hamstrings are relaxed. Hamstring contraction can produce a false negative

Anterior Drawer Test

LIGAMENTOUS STABILITY (anterior instability)

Purpose

• ACL integrity

How to perform

1. pt supine w/ 90° knee flexion or slightly less

2. Stabilize the foot by sitting on it

3. Place both hands around the proximal tibia with the thumbs near the joint line

4. Translate the tibia anteriorly

5. Assess the amount of translation and the end feel

Positive test

• Excessive anterior tibial translation

• Soft end feel

Pivot Shift Test - Needs Work

LIGAMENTOUS STABILITY (anterior instability)

Purpose

• ACL tear

• Anterolateral rotary instability

• Assesses dynamic anterior subluxation and reduction of the tibia in an ACL-deficient knee - youtube

• Assesses anterolateral rotatory instability/anterior translation of the tibia relative to the femur - CPG

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How to perform - Youtube

1. pt supine w/ the hip flexed and abducted 30°

2. Grasp the calcaneus from the outside to create tibial IR (some authors add axial compression)

3. Apply a slight valgus force at the level of the fibula

4. Move the knee from extension into flexion while maintaining the forces

How to perform - CPG

1. pt supine w/ knee fully extended

2. IR the tibia holding at the ankle w/ hand 1

3. Place hand 2 on the lateral aspect of the proximal tibia

4. Apply a valgus stress while slowly flexing the knee from full extension

5. Look for a sudden reduction at approximately 20° of knee flexion = ACL tear

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Positive test - Youtube

• The tibia reduces or drops posteriorly at approximately 30–40° knee flexion as the IT band tightens

• A palpable or audible clunk may occur

• The patient may report the familiar giving-way sensation experienced during walking

Positive test - CPG

• A sudden clunk or shift as the anteriorly subluxed lateral tibial plateau reduces at approximately 20° knee flexion = ACL disruption

• Grading

  • Normal = equal/no shift

  • Grade 1 = glide

  • Grade 2 = clunk

  • Grade 3 = gross/severe shift

Posterior Drawer Test

LIGAMENTOUS STABILITY (posterior instability)

Purpose

• Posterior instability

• PCL tear

How to perform

1. pt supine w/ knee at 90° and the foot in neutral

1. Stabilize the foot by sitting on it

2. Place both hands on the proximal anterior tibia w/ thumbs on the medial and lateral joint lines

3. Translate the tibia posteriorly

4. Compare the amount of movement with the opposite side

5. Translation may be estimated or measured in millimeters

Positive test

• Greater posterior tibial movement on the affected side than the unaffected side = PCL tear

  • Aka more posterior motion vs the unaffected side

Posterior Sag Test

Godfrey’s Test

LIGAMENTOUS STABILITY (posterior instability)

Purpose

• Posterior tibial instability

• PCL tear

How to perform

1. pt supine with the hips and knees at 90°

2. Support both lower legs and heels

3. Compare & palpate tibial tuberosities

4. Optional: have pt contract hamstrings to increase posterior tibial translation

Positive test

• The proximal tibia sags posteriorly on the affected side?? A torn PCL lets the tibia sag backward???

• Affected tibial tubercle less visible than unaffected side = PCL tear

McMurray’s Test

LIGAMENTOUS STABILITY + MENISCUS

Purpose

• Torn medial or lateral meniscus

How to perform

1. pt supine

2. Grasp heel & flex hip and knee to approximately 90°

3. Palpate the medial and lateral tibiofemoral joint lines with the thumb and index finger of opposite hand

4. When the knee is flex, rotate the tibia

   1. Medial meniscus → ER

   2. Lateral meniscus → IR

5. Slowly extend the knee (some variations include simultaneous valgus force)

Positive test

• Audible or palpable thud, pop, or click (, especially when accompanied by joint-line pain???

• Pain reproduction

Apley’s Test

LIGAMENTOUS STABILITY + MENISCUS

Purpose

• Rotation sprain of the soft tissue

• Meniscal tear

How to perform

1. pt prone w/ knee at 90°

2. Stabilize the femur by half-kneeling over the pt’s hamstring

3. Grab pt’s foot w/ both hands

4. During the distraction phase, distract the tibia and rotate it

5. During the compression phase, compress through the foot and rotate the tibia

6. Compare the symptoms produced during compression and distraction.

Positive findings and interpretation

• Worse pain during rotation = rotation sprain of the soft tissue

• More pain with compression than distraction = meniscal tear

Bounce-Home Test

MENISCUS

Purpose

• Meniscal pathology

How to perform

1. pt supine w/ slight knee flexion

2. Support underneath the knee as a guide

3. Allow the knee to move quickly and passively into extension

Positive test

• Joint-line pain with an inability to reach full extension = meniscal pathology

• Anterior pain over the infrapatellar fat pad may suggest a different source.

Clinical pearl: Bounce-home is not diagnostic by itself and should be interpreted as part of a cluster of findings

Thessaly Test

Disco Test

LIGAMENTOUS STABILITY + MENISCUS

Purpose

• Meniscal tear or injury

• Note: the only loaded meniscal test → better stats

How to perform

1. pt standing on involved leg at 20° knee flexion (provide support as needed)

2. Have pt IR & ER (femur on tibia) 3x in each direction

Positive test

• Medial or lateral joint-line pain

• Sense of catching/locking

Eccentric Step-Down Test

LIGAMENTOUS STABILITY + “Patellofemoral & Other”

Purpose

• Patellofemoral dysfunction

• May be used as a functional screen or knee-rehabilitation exercise

How to perform

1. pt stands on a six-inch step or stool

2. Have the pt keep trunk straight as they lower one leg until the heel touches the floor

   1. Test unaffected side before affected side (which side is affected??)

3. Assess anteriorly, posteriorly, and laterally

4. Palpate knee for crepitus if needed

Positive or abnormal findings

• Any pain during the step down

• Compensations: increased mvmt, trunk lean, loss of pelvic height symmetry (hip drop), increased femoral IR, increased knee mvmt in transverse plane

Zohler Sign

Clarke’s Sign

Purpose

• Patellofemoral pain or chondromalacia

• May identify irritation or roughening of the patellar articular surface

How to perform

1. pt supine w/ knees extended & quads relaxed

2. Glide the patella slightly inferiorly & apply gentle compression/resistance to superior patellar movement

3. Ask the pt to contract the quadriceps while the patella is held

Positive test

• Reproduction of patellofemoral pain

• Marked crepitus during quadriceps contraction

Unilateral Squat

Waldron Test

Purpose

• Patellofemoral dysfunction during loaded knee flexion

How to perform

1. pt standing on test leg

2. Ask pt to perform a slow, partial single-leg squat

3. Observe patellar tracking, trunk/pelvic control, femoral rotation, knee alignment, and balance

4. Palpate around the patellofemoral joint may be used to identify pain or crepitus and the knee flexion angle at which sx occurs

Positive test

• Patellofemoral pain or crepitus during the squat

Clinical pearl: Abnormal tracking or loss of lower-quarter control should be documented, but it is not tissue-specific by itself

Q-Angle Measurement

Purpose

• Estimates the quadriceps’ line of pull & tendency for lateral patellar tracking

How to perform

1. pt supine

2. Identify the ASIS, center of the patella, and center of the tibial tubercle

3. Measure the angle between:

   1. ASIS to patella center

   2. patella center to tibial tubercle

Course values

• Males: approximately 8–14°

• Females: approximately 15–17°

Interpretation

• Values above approximately 15–20° may be concerning.

• The lecture notes describe an angle greater than 20° as abnormal and potentially associated with lateral patellar displacement.

Clinical pearl: Interpret the Q-angle with symptoms, patellar tracking, and dynamic movement rather than alone.

Medial Patellar Plica Test

Mediopatellar Plica Syndrome

LIGAMENTOUS STABILITY + “Patellofemoral & Other”

Purpose

• Medial patellar plica syndrome

How to perform

1. pt supine

2. Glide the patella medially and hold it

3. Passively IR tibia & flex knee

4. Passively extend knee from the flexed position

Positive test

• A palpable clunk under the patella as the knee extends = medial patellar plica syndrome

Hughston's Plica Test

Mediopatellar Plica Test

Noble’s Compression Test

LIGAMENTOUS STABILITY + “Patellofemoral & Other”

Purpose

• Iliotibial band friction syndrome

How to perform

• pt supine or side-lying w/ hip & knee at 90° (w/ bolster under knees on table - not stated)

• Apply pressure over the lateral femoral condyle directly over the IT band

• Maintain the compression while the patient actively extends the knee

Positive test

• Pain before or at 30° knee flexion = iliotibial band friction syndrome

  • Pain at <30° is negative

Stroke or Fluid-Displacement Test

Purpose

• Knee-joint effusion

How to perform

1. pt supine

2. Using the palm w/ a flat hand, sweep fluid upward (“up and out”) along the medial side of the knee from distal to proximal 2-3x

3. Sweep downward along the lateral side toward the knee

4. Watch the medial side for refilling

Positive test

• A visible return of fluid on the medial side following the medial upstroke and lateral downstroke = knee-joint effusion

Grading

• Zero: no wave produced on downstroke

• Trace: small wave on medial side with downstroke

• 1+: larger bulge on the medial side with downstroke

• 2+: effusion spontaneously returns to the medial side after the upstroke (no downstroke necessary)

• 3+: so much fluid that it is not possible to move the effusion out of the medial aspect of the knee

Navicular Drop Test

Purpose

• Excessive medial longitudinal arch collapse

• Abnormal pronation

How to Perform

1. Pt seated

2. Place subtalar joint in neutral

3. Palpate and mark the navicular tubercle height from the floor using an index card

4. Have pt stand

5. Repeat measurement and calculate the difference

Positive Test

• Navicular drop >10 mm

Too Many Toes Sign

Purpose

• Abnormal pronation

• Flat-foot posture

How to Perform

1. Pt standing

2. Observe the calcaneus and toes from directly behind the pt

Abnormal Test

• Abnormal: more than the 5th toe and half of the 4th toe are visible lateral to the calcaneus

• Normal: only the 5th toe and approximately half of the 4th toe are visible

Windlass Test

Purpose

• Assess the windlass effect of the plantar fascia

• Assess the response of the medial longitudinal arch

How to Perform

1. Pt stands completely relaxed in a natural base of support

2. Passively extend the hallux with one hand

3. Place the other hand around the calf to ensure the pt is not using muscle activity

4. Observe the medial longitudinal arch

Abnormal Test

• Abnormal: medial longitudinal arch fails to rise with hallux extension

• Normal: the arch rises as the great toe is extended

Anterior Drawer Test

Purpose

• Assess Anterior TaloFibular Ligament (ATFL) stability

How to Perform

1. Pt seated or supine w/ bolster under knees w/ gastrocnemius and soleus relaxed

2. Stabilize the distal leg and grasp the heel

3. Position the ankle in 10–20° PF

4. Pull the heel anteriorly, or move the tibia posteriorly

5. Compare movement and end feel with the uninvolved side

Positive Test

• Pain and/or increased movement compared to uninvolved side

Talar Tilt Test

NEEDS CHECKING

Purpose

• Assess the integrity of the ankle ligaments:

  • CFL

  • ATFL

  • Deltoid ligament

How to Perform

1. Pt supine with a bolster under the knees or side-lying with the knee flexed and foot relaxed

2. Stabilize the distal leg and grasp the calcaneus

3. With the ankle in neutral, apply inversion/adduction stress

4. Repeat in 10–20° PF with inversion/adduction stress

5. Apply eversion/abduction stress to assess the medial ankle

6. Compare pain, laxity, and end feel with the uninvolved side

Positive Test

• Pain and/or increased laxity compared with the uninvolved side

Interpretation

• Neutral + inversion/adduction → CFL

• 10–20° PF + inversion/adduction → ATFL

• Eversion/abduction → deltoid ligament

Easy way to remember

• Foot tilts inward → lateral ligaments

• Foot tilts outward → medial deltoid ligament

Squeeze Test

Purpose

• Assess the distal tibiofibular syndesmosis for a high ankle sprain

How to Perform

1. Pt supine with a bolster under the knees or side-lying

2. Squeeze the syndesmosis (tibia and fibula) together above the malleoli

Positive Test

• Pain in the distal 1/3 of the leg

• Pain occurs distal to the area being squeezed

Rule Out

• Tibia or fibula fracture, calf contusion, compartment syndrome

Kleiger Stress Test

ER Stress Test

Purpose

• Assess the distal tibiofibular syndesmosis for a high ankle sprain

• Assess for a deltoid ligament tear

How to Perform

1. Pt seated with the legs over the edge of the table and knee flexed to 90°

2. Stabilize the lower leg with one hand

3. ER the foot with the other hand

Positive Test

• Reproduction of ankle pain

  • Anterolateral distal tibiofibular pain → high ankle sprain

  • Medial ankle pain → deltoid ligament tear

Thompson Test

Purpose

• Assess for a complete Achilles tendon rupture

How to Perform

1. Pt prone with feet relaxed over the edge of the table

2. Squeeze the calf muscle

3. Observe the ankle for PF

Positive Test

• Absence of PF when the calf is squeezed = complete Achilles tendon rupture

Morton’s Test

Purpose

• Stress fracture

• (Morton’s?) neuroma

How to Perform

1. Pt supine w/ bolster under knees

2. Squeeze the metatarsal heads together

3. Monitor the pt’s symptoms

Positive Test

• Reproduction of forefoot pain = stress fracture or neuroma

Homan’s Test

Purpose

• Deep Vein Thrombosis (DVT)

How to Perform

1. Pt supine with knees extended

2. Stabilize the thigh & passively DF the ankle

3. Monitor for calf symptoms

Positive Test

• Calf pain with passive DF

Important Limitation

• Poor sensitivity and specificity

• Positive in fewer than 30% of pts with DVT

Figure-of-8 Measurement

Purpose

• Ankle edema measurement and tracks change over time

How to Perform

1. Pt supine or seated with ankle in a neutral or comfortable position

2. Start midway between the tibialis anterior tendon and lateral malleolus

3. Pass the tape:

   • Just distal to the navicular tuberosity

   • Across the plantar arch toward the 5th metatarsal base

   • Across the tibialis anterior tendon

   • Just distal to the medial malleolus

   • Across the Achilles tendon

   • Back just distal to the lateral malleolus

4. Record the circumference using the same landmarks each time

Result

• This is a measurement, not a positive/negative test

• Larger value compared with the opposite side or a prior measurement → greater edema

Weight-Bearing Lunge Test

Purpose

• Assess weight-bearing ankle DF ROM

How to Perform

1. Mark 10 cm from a wall using tape

2. Align the foot so an imaginary line through the heel and great toe points toward the wall

3. Lunge forward and attempt to touch the knee to the wall while keeping the heel on the floor

Positive Test

• Failure to touch the knee to the wall from 10 cm → restricted DF / ankle stiffness

  • May reflect decreased joint mobility or soleus tightness