Knee Complex Examination Flashcards
Flexion ROM
10-0-135
Extension ROM
135-0-10
Tibiofemoral joint resting position
25 degrees of flexion
Tibiofemoral joint closed pack position
Full extension
Full lateral rotation of tibia
Ottawa Knee Rules
>55 years old Tenderness at the head of the fibula Isolated tenderness of the patella Inability to flex knee to 90 degrees Inability to walk four WB steps immediately after injury and in the emergency room -Sensitive test
Pittsburgh Decision Rules
Blunt trauma or a fall as MOI and either of the following
-Age less than 12 or greater than 50
-Inability to walk four WB steps in the ER
Highly sensitive and more specific than Ottawa Knee Rules
Clicking
Meniscus tear
Snapping
Synovial plica
Tendon over bone
Grating
Chondromalacia
OA
Osteochondritis
Tearing
Muscle
Ligament
Catching
Meniscal Tear
Subluxing patella
Popping
ACL
Meniscus
Muscle
Tingling
Nerve
Circulation
Worse in morning
Arthritis
Chronic inflammation
Worse up stairs
Anterior horns of the meniscus
Worse down stairs
Posterior horns of the meniscus
Potential Pathologies of the knee
Patellofemoral dysfunction Meniscal injury Ligamentous sprain or laxity Capsular restriction Musculotendonous strain ITB syndrome Tendonitis, Bursitis, synovitis OA/RA Fractures s/p TKA s/p Scope s/p ACL repair
Chrondromalacia patella
MOI: repetitive trauma, patellar misalignment
S/S: retropatellar pain
Functional Complaints: Aggravated doing stairs, running, squatting
Patellar subluxation/Dislocation
MOI: Lateral tightness, Q angle, Repetitive trauma, acute trauma
S/S: Apprehension, Pain, swelling
Patellar Tendonitis
MOI: Repetitive trauma, insidious, sports w/ eccentric load to quads
S/S: Anterior knee pain, Pain at inferior pole of patella
Functional complaints: Jumping or kneeling, during or after activity
Pre-patellar bursitis
MOI: Repeated friction, trauma, repetitive trauma
S/S: Redness, effusion over the patella
Functional complaints: difficulty walking, inability to kneel
Meniscal Injury
Valgus or Varus force applied to flexed knee Forced medial rotation: lateral meniscus Forced Lateral rotation: Medial meniscus S/S: -Acute joint line pain -Effusion -Locking, click, snap -Catching sensation -Giving way
ACL injury
MOI: Sudden cut or deceleration, rotation combined with varus or valgus, hyperextension S/S: -Pop -Swelling -Persistant pain unless full tear -Hemarthrosis -Loss of ROM Functional c/o giving way
PCL Injury
MOI: Hyperflexion, Hyperextension, rotational motion w/ varus or valgus S/S: -Pop -Diffuse or posterior knee pain -Swelling -Hemarthrosis Functional c/o inability to bear wait
MCL injury
MOI: valgus force, excessive lateral rotation, overuse S/S: -localized pain and stiffness -Ecchymosis after several days -Swelling
LCL Injury
MOI: Varus force, excessive lateral rotation S/S: -localized pain and stiffness -Echymossis -Swelling
Capsular restriction
MOI: Long period of lack of movement through ROM
Flexion more limited than extension
Musculotendinous injury
MOI: -Poor footwear -Tight muscles -Overuse -Muscle imbalance S/S -Pain with active contraction and passive lengthening
ITB Syndrome
MOI: Repetitive use, misalignment
S/S: Pain at lateral aspect of knee
Functional c/o: worse w/ activity, may pop during movement
Baker’s cyst
MOI: associated w/ OA, RA, Gout S/S: -Popliteal mass or swelling -Aching -Knee effusion May be associated with medial meniscus damage
Location of swelling
30 min to 2 hours is hemarthrosis
-potentially ACL, patellar sub/dislocation, PCL, Fx, meniscus
6-24 hours after is synovial origin
-meniscal tear, bone chips, capsular sprain, MCL, patellar sub
Patella Baja
Patella sits lower than expected
Patella Alta
Patella sits higher than expected
Camel sign
Osgood Schlatter
MOI: Indirect trauma, repetitive stress, sudden powerful quad contraction, repeated knee flx against tight quads
S/S:
-ache/pain at tib tubercle
-enlarged tubercle
-swelling
-Heat and tenderness over area
-Pain increased by activity that tensions tuberosity
5 reasons to perform LQS
- Insidious onset
- Referred or radicular pain
- Doubt about the location of pathology
- Altered sensation
- Unusual pattern of symptoms
Hip flexor flexibility
Two joint hip flexor test (Thomas test)
ITB/TFL flexibility
Ober’s test
Hamstring flexibility test
90/90 position
Patellar ballotment test
Pt in long sit
Examiner w/ one hand above and below knee
Press over middle of patella in posterior direction
Positive if the patella flows back to its original position
Ballotment
Major effusion
Mediopatellar Plica test
Pt supine with knee flexed 10-20, leg supported
Palpate for fold in capsule medial to patella
Move patella medially over plica to pinch
Positive if painful
Clark’s sign (Patellar grind test)
Pt supine with knees supported Use web of hand, press down proximal to superior pole Pt contracts quad Positive if crepitus or pain -Questionable chrondromalacia patella
Measure Q angle
Higher Q angle leads to higher likelihood of lateral tracking Pt supine with knee full extension Fulcrum on patella Stationary arm ASIS Movement arm Tibial tubercle
Patellofemoral Joint Apprehension test
Lateral patellar gilde:
-Pt with knees in full extesion
-Thumbs on medial border of patella push lateral
-Test repeated at 20 and 45 degrees
Positive if patella glides laterally >1/4 its width
Medial Patellar glide:
-same as above but pushing medial
Positive if patella glides >30-40% of width or >10mm
Figure 4 Test
- Pt supine and places ankle of affected knee on contralateral knee
- Examiner pushes affected knee towards table
- Positive is concordant pain over lateral joint line at popliteal hiatus indicates lateral meniscus tear
Payr’s signs
Figure 4 test but patient complains of medial knee pain
Indicates posterior horn lesion of medial meniscus
Squat test/Duck waddle/Childress test
- Pt standing then squats
- If no pain, duck walks in squat
- Positive if a block preventing full flexion or pain at end range flexion indicates meniscal tear
Dynamic Test
-Pt supine with hip abd 60, flexed 45, and ER; knee flexed to 90, lateral border of foot on table
-Palpate lateral joint line then slowly adduct the hip while maintaining flx
-Positive if sharp pain at end of hip add or increase in pain
Indicates lateral meniscal tear
Thessaly Test at 5 degrees
- Pt stands on one leg and grasps examiners hands
- Pt flexes knee to 5 degrees and rotates R and L
- Repeat R to L motion 3 times
- Positive if joint line discomfot and sense of locking or catching
- Indicates meniscal tear
Thessaly test at 20 degrees (Disco Test)
- Pt stands on one leg and grasps examiners hands
- Flexes knee to 20 degrees and rotates R and L 3 times
- Positive if joint line discomfort and sense of locking or catching
- Indicates a meniscal tear
McMurray Click Test
Pt supine examiner stand on involved side
Grasp at heel, flex knee to end range while palpating medial and lateral joint line
-ER and extend knee to asses medial meniscus
-IR and extend knee to assess lateral meniscus
Positive if audible or palpable thud or click
Apley’s test
Pt prone
Examiner places knee on HS of pt with pt knee flx to 90
Grasp foot w/ both hands, distract tibia and rotates tibia
-Positive if pain with rotation indicates soft tissue rotation sprain
Examiner compresses tibia and rotates
-Positive if worse with compression than distraction indicitive of meniscal tear
Valgus Stress Test
Pt supine with hip slightly ABD
Knee flexed to 30
Examiner applies medially directed force at lateral joint line while hand at ankle slightly ER lower leg
Repeat the test at full extension
-Positive if excessive medial opening and concordant pain implicates MCL
-If the test is positive at 0 degrees then the ACL/PCL and/or joint capsule is implicated
Varus Stress Test
Pt supine with hip slightly ABD
Knee flexed to 30
Examiner applies laterally directed force at medial joint line while hand at ankle slightly IR the lower leg
Repeat test with full extension
-Positive if excessive lateral opening and concordant pain implicates LCL
-If the test is positive at 0 degrees then the ACL/PCL and/or joint capsule is implicated
Posterior Sag Sign (Godfrey’s Test)
Pt supine with hip and knee flexed to 90 degrees
Examiner or chair supports leg under calf/heel
Positive if posterior sagging of the tibia secondary to gravitational pull implicates PCL
Posterior Draw test
Pt supine with knee flexed to 90, hip flexed to 45, and neutral foot
Examiner sits on pt foot to stabilize
Both hands on proximal anterior tibia with thumbs on medial and lateral joint lines
Proximal tibia is translated posteriorly
Repeat with foot IR and ER
-Positive dependent on motion compared to other side implicates PCL
Grades 1-3 with 3 being most lax
Anterior Draw test
Pt supine with knee flx to 90 so foot is flat
Examiner sits on foot and grasps behind proximal tibia w/ thumbs on tibial plateau
Anterior tibial force applied
Positive if greater anterior displacement when compared to unaffected side implicates ACL
Lachman’s test
Pt supine with knee flexed to 15 degrees
Examiner stabilizes distal femur with one hand and grasps proximal tibia with other
Examiner applies anterior force to tibia
Positive if greater anterior displacement on affected side when compared bilaterally
Implicates ACL
Hughston’s Test
Pt hooklying knee at 90 with 10 degrees IR/ER
Examiner sits on patients foot
Apply posterior forces moving tibia on femur while palpating joint line
Excessive motion with IR is Posteromedial Rotary Instability
Excessive motion with ER is Posterolateral rotary instability
Slocum Tests
Pt hooklying with knee at 90 with IR/ER
Examiner sit on foot
Apply anterior force of tibia on femur while palpating joint line
Excessive motion with IR is Anterolateral rotary instability
(greatest at 30 degrees IR)
Excessive motion with ER is Anteromedial rotary instability (greatest at 15 degrees ER)
Pivot Shift (Test of Macintosh)
Pt supine
Position LE in 10-15 degrees flexion and IR tibia and apply a valgus force with hand along lateral joint line
Slowly flex knee beyond 30 maintaining rotation
Positive if audible or palpable click or thud
Rotary instability
Reverse Pivot Shift (Jakob test)
-Pt lies supine with knee flexed to 70-80 with ER of tibia
-Gravitiy assists the knee into extension as examiner leans slightly against the foot and provides valgus force
-As the knee approaches 20 degrees flexion, you can feel and see lateral tibial plateau move anteriorly from a posterior subluxation
-Positive test is a reduction of the tibial head
Rotary instability
Ober’s Test
Pt sidelying, hip and knee flexed
PT extends and ABD upper leg passively
Allow the leg to lower towards table while stabilizing pelvis
Performed with knee flexed and extended
Positive if leg remains ABD, contracture of ITB is present
Nobel Compression Test
Pt supine with knee flexed to 90 and hip flexed
PT applies pressure over lateral femoral condyle or 1-2 cm proximal
Pt extends knee while PT maintains pressure
Positive if PT reports extreme pain over lateral femoral condyle at 30 of flexion = ITB friction syndrome
Functional Testing
Squat Stairs Walk Run Kneeling LE Balance and Reach
