Knee Practical Flashcards
One Plane Lateral Instability
- Varus Stress Test With knee in slightly flexed
2. Varus Stress Test With knee in full extension
One Plane Medial Instability
- Valgus Stress Test With knee slightly flexed
2. Valgus Stress Test With knee in full extension
One Plane Anterior Instability
- Lachman Test
2. Anterior Drawer Test
One Plane Posterior Instability
- Posterior Sag Sign
- Posterior Drawer Test
- Reverse Lachman Test
Anteromedial Rotary Instability
- Slocum test
Anterolatereal Rotary Instability
- Slocum Test
2. Lateral Pivot Shift Test
Posteromedial Rotary Instability
- Hughston’s posteromedial drawer Test
Posterolateral Rotary Instability
- Houghston’s posterolateral drawer Test
Squat walk
- Squat and walk with feet in IR: lateral meniscus pain
2. Squat and walk with feet in ER: medial meniscus pain
Medial Meniscal Tests:
- McMurry for Medial Meniscus (valgus + ER of the tibia and extend knee)
Lateral Meniscal Tests:
- McMurry for Lateral Meniscus (varus + IR of the tibia and extend knee)
Both Menisci together–not to discrimnate
- Apley’s Test: (part 1 grinding in prone, knee flex 90 deg-part two checks ligaments)
- Bounce Home Test (supine, knee flex drop to extend)
- Helfet Test (dot on tibial tubercle and medial patella-screw home mechanism obstruct)
also: tender along joint line
walk with feet in IR/ER
Tests for swelling in the knee
- Wipe Test
- Patella Tap
- Indentation Test
Dx for knee effusion
- self noted knee swelling
- positive ballottmemt/patella tap test
standard reference: MRI with intra-articular fluid within the infrapatellar/medial/or lateral compartment
Tests For Plica
Tests for Plica Syndrome–mediopatella plica test
Position: supine
Joint angles: flex knee 30 degrees
Motion: push patella medially
Results:
1st indicator: pain as push patella medially which depresses the plica under the patella (medial femoral condyle)
If that does not illicit pain: strum finger in space medial to the patella and find a guitar string wire=plic [most have some discomfort there]
Test for Patellofemoral Dysfunction
- Patellafemoral Grinding Test
- Clarke’s Sign
- Patella Stability Test
- Fairbank’s Test
- Waldron Test
Joint Mobility Testing of the Knee: Patella
- Patella Distraction
- Superior Glide
- Inferior Glide
- Medial Glide
- Lateral Glide
- Inferior technique for stiffness (for extension)
Joint Mobility Testing of the Knee: Tibia
- Distraction of the tibia
- Anterior Glide of Tibia
- Posterior Glide of Tibia
- Lateral Glide of Tibia
- Medial Glide of Tibia
- Treatment of Hypermobile Knee
Varus Stress Test With knee in slightly flexed
Position: Joint angles: Hand placement: Motion: Results: Positive:
LCL,
posterolateral capsule, arcuate-popliteus complex, ITB, bicep femoris tendon
Position: supine
Joint angles: knee slightly flexed to 30 degrees
Hand placement:
- stand at side of table.
- mobilizing hand: hold patient ankle proximal to malleolus between elbow and trunk to secure the leg.
- stabilizing hand: distal medial femur (use fingers to palpate opening joint space on lateral side)
Motion: apply varus force to the knee by pulling the distal tibia medially while stabilizing the medial distal femur.
Results: Expect gapping on lateral side of knee joint and abrupt and firm ligamentous end feel.
Positive: loss of LCL integrity: increased gapping, not a firm ligamentous end feel, clunk as you release.
Varus Stress Test With knee in full extension
Position: Joint angles: Hand placement: Motion: Results: Positive:
LCL,
posterolateral capsule, arcuate-popliteus complex, bicep femoris tendon, ACL, PCL, lateral gastroc
Position: supine
Joint angles: knee extended
Hand placement:
- stand at side of table.
- mobilizing hand: hold patient ankle proximal to malleolus between elbow and trunk to secure the leg.
- stabilizing hand: distal medial femur (use fingers to palpate opening joint space on lateral side)
Motion: apply varus force to the knee by pulling the distal tibia medially while stabilizing the medial distal femur.
Results: Expect gapping on lateral side of knee joint and abrupt and firm ligamentous end feel.
Positive: loss of LCL integrity: increased gapping, not a firm ligamentous end feel, clunk as you release.
Valgus Stress Test With knee slightly flexed
Position: Joint angles: Hand placement: Motion: Results: Positive:
Tests: MCL, posterior oblique ligament, PCL (all other structures on slack)
Position: supine
Joint angles: knee slightly flexed to 30 degrees
Hand placement:
- stand at side of table.
- mobilizing hand: hold patient ankle between elbow and trunk to secure the leg.
- stabilizing hand: distal lateral femur (use fingers to palpate opening joint space on medial side)
Motion: apply valgus force to the knee by pulling the distal tibia laterally while stabilizing the lateral distal femur.
Results: Expect gapping on medial side of knee joint and abrupt and firm ligamentous end feel.
Positive: loss of MCL integrity: increased gapping, not a firm ligamentous end feel, clunk as you release.
+++if Valgus Stress Test With knee in extension is also positive suspect MCL and PCL
Valgus Stress Test With knee in full extension
Position: Joint angles: Hand placement: Motion: Results: Positive:
Tests:
Position: supine
Joint angles: knee extended
Hand placement:
- stand at side of table.
- mobilizing hand: hold patient ankle prox to malleolus between elbow and trunk to secure the leg.
- stabilizing hand: distal lateral femur (use fingers to palpate opening joint space on medial side)
Motion: apply valgus force to the knee by pulling the distal tibia laterally while stabilizing the lateral distal femur.
Results: Expect gapping on medial side of knee joint and abrupt and firm ligamentous end feel.
Positive: loss of MCL integrity: increased gapping, not a firm ligamentous end feel, clunk as you release.
+++if Valgus Stress Test With knee in flexion is also positive suspect MCL and PCL
Lachman Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
Tests: ACL, *** posterior lateral band (0-20 degrees flex)
posterior oblique ligament, arcuate-popliteus complex
Position: Supine,
Joint angles: 0-20 degrees of knee flexion
Hand placement: my knee is under the patient femur to create the 0-20 degree knee flexion. Stabilizing hand on the distal femur to prevent it from sliding, mobilizing hand under proximal tibia
Motion: slightly ER the tibia and draw the tibia anteriorly to pull the fibers of the posteriorlateral band of the ACL
Results: Feel the ACL restraining the movement of the tibia going forward
Positive: damage to posteriorlateral band ACL
Anterior Drawer Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
ACL***anterior medial band (70-90 degrees of flexion)
posterolateral capsule, posteromedial capsule, MCL, ITB, posterior oblique ligament, arcuate-popliteus complex
Position: Hookline
Joint angles: knee flexed 90 degrees
Hand placement: sit on patient foot to prevent slide to knee extension. hand behind superior posterior tibia with thumbs on tibial plateaus palpating joint lines
Motion: take up the soft tissue of the gastroc posteriorly while thumbs on tibial plateaus anteriorly, pull the tibia anteriorly on the femur
Results:
Positive: Too much motion: concern of instability of the ligament
Note: Stable: KT1000 below 3mm
in Mobility test: Not enough movement: concern of mobility restriction (needed for full knee extension) is
Posterior Sag Sign
Godfrey Sign
Position: Joint angles: Hand placement: Motion: Results: Positive:
PCL
Position: hookline Joint angles: Hand placement: Motion: Results: PCL should be aligned with femur and prevent the tibia moving posteriorly against gravity
Positive: tibia will not be aligned with femur and will sag back if PCL deficient
high sensitive–ask her about this
DO THIS TEST FIRST: Creates false negatives on the posterior drawer test since it is already far back an false positives on the anterior drawer test since there is space for it to come back to neutral
Posterior Drawer Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
PCL ***anterior fibers
arcuate popliteus complex, posterior oblique ligament, ACL
Position: Hookline
Joint angles: knee flexed 90 degrees
Hand placement: sit on patient foot to prevent slide to knee extension. hands around the tibia so that the heels of your hands rest on the medial and lateral tibial plataues with fingers wrapped around the medial and lateral joint spaces
Motion: push the tibia in a posterior direction until the slack has been taken up
Positive: PCL lost integrity
Mobility test: posterior glide of the tibia–posterior mobility of the femoral tibia joint
Reverse Lachman Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
PCL ***posterior fibers
arcuate popliteus complex, posterior oblique ligament, ACL
Position: PRONE
Joint angles: knee flexed 20-30 degrees
Hand placement: stabilize at distal femur, bring other arm up and over the leg in order to use the thenar eminance to push the tibia from the anterior side of it in the posterior direction
Motion: push the tibia in the posterior direction
no rotational component
Results: should have a firm abrupt end feel
Positive: PCL ***posterior fibers
Slocum test
Position: Joint angles: Hand placement: Motion: Results: Positive:
- for anteromedial rotary instability
MCL, posterior oblique ligament, posteromedial capsule, ACL
Position: supine, hookline
Joint angles: 90 degrees of knee flexion, tibia ER (15 degrees)
Hand placement: sit on foot to hold in ER. hand behind superior posterior tibia with thumbs on tibial plateaus palpating joint lines, take up the soft tissue of the gastroc posteriorly while thumbs on tibial plateaus anteriorly
Motion: pull the tibia anteriorly on the femur
Results: as we laterally rotate the leg the medial part of the tibia comes forward creating more tension on medial component of the knee joint and thus the test looks at anterior and MEDIAL stability.
Positive: anterior movement occurs mostly on the medial side of the knee - for anterolateral rotary instability
ACL, posterolateral capsule, arcuate-popliteus complex, LCL, ITB (ITB stabilizes lateral aspect of every position)
Hand placement: sit on foot to hold in IR.
Motion: pull the tibia anteriorly on the femur
Results: as we medially rotate tibia the lateral part of the tibia comes forward creating more tension on the lateral component of the knee joint and thus looks at anterior and LATERAL stability.
Positive: anterior movement occurs mostly on the lateral side of the knee
Lateral Pivot Shift Test = Test of Macintosh
Position: Joint angles: Hand placement: Motion: Results: Positive: False negative:
ACL*posterolateral capsule, arcuate-popliteus complex, LCL, ITB
Position: supine
Joint angles: Hip is 20 degrees flexed, some abduction,
Knee is flexed 5 degrees
Hand placement: -hand at lateral tibial plateau near the fibular head -other around malleoli
Motion: Apply tibia IR and Valgus—-then flex the knee to 40 degrees
Results: feel what happens at the lateral tibial plateau
POSITIVE: knee feels unstable, there is a clunk with reduction:
—- the anterior lateral component of the tibia will sublux forward as you bring in the rotation with valgus to 40 degrees of flexion
—-ITB will become a flexor because it goes behind the axis of the knee joint and it will reduce the tibia: it will pull on the tibia that dislocated/subluxed back into position and the clunk can be heard
FALSE NEGATIVE: cases of ACL tear but negative lateral pivot shift test:
1. ITB not intact 2. meniscal tear
Hughston’s posteromedial drawer Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
PCL, posterior oblique ligament, MCL, semimembranosus, posteromedial capsule, ACL
Position: Hookline
Joint angles: knee flexed 90 degrees
Tibia IR
Hand placement: sit on patient foot to prevent slide to knee extension.
hands around the tibia so that the heels of your hands rest on the medial and lateral tibial plataues with fingers wrapped around the medial and lateral joint spaces
Motion: push the tibia in a posterior direction until the slack has been taken up
Positive: if excess movement of the medial tibia occurs, indicates PCL, MCL, and posteromedial capsular damage
Houghston’s posterolateral drawer Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
PCL, arcuate-popliteus ligament, LCL, bicep femoris tendon, posterolateral capsule, ACL
Position: Hookline
Joint angles: knee flexed 90 degrees
Tibia ER
Hand placement: sit on patient foot to prevent slide to knee extension.
hands around the tibia so that the heels of your hands rest on the medial and lateral tibial plataues with fingers wrapped around the medial and lateral joint spaces
Motion: push the tibia in a posterior direction until the slack has been taken up
Positive: excess movement of the lateral tibia:
PCL, LCL, and posterolateral capsule damage
Squat with feet in IR: lateral meniscus pain
quick test: if put tibia in IR and squat feel pressure on lateral side = EGE test
Squat with feet in ER: medial meniscus pain
quick test: if put tibia in ER and squat feel pressure on medial side
McMurry Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
one for medial mensicus
one for lateral meniscus
McMurry for Lateral Meniscus
Position: Joint angles: Hand placement: Motion: Results: Positive:
Position: supine
Joint angles: hip and knee flexed 90-90
Hand placement: one hold at malleolus (so not move ankle around) and the other hold knee at popliteal fossa above knee joint. internally and externally rotate the tibia to loosen it up
Motion: Tibia IR + VARUS, hold this and EXTEND KNEE
Results:
Positive: Pain + Clicking indicate damage of lateral mensicus
McMurry for Medial Meniscus
Position: Joint angles: Hand placement: Motion: Results: Positive:
Position: supine
Joint angles: hip and knee flexed 90-90
Hand placement: one hold at malleolus (so not move ankle around) and the other hold knee at popliteal fossa above knee joint. internally and externally rotate the tibia to loosen it up
Motion: Tibia ER + VALGUS, hold this and EXTEND KNEE
Results:
Positive: Pain + Clicking indicate damage of medial mensicus
Apley’s Test:
Position: Joint angles: Hand placement: Motion: Results: Positive:
performed to assess whether medial/lateral joint line pain is due to meniscus or collateral ligament damage
PART 1: Grinding: Meniscus
Position: PRONE
Joint angles: knee flexed 90 degrees
Hand placement: femur stabilized with my knee.
—hold foot through calcaneus and other hand around malleoli
Motion: internally rotate and externally rotate the tibia while applying a downward force through calcaneus/mortis –grind meniscus
Positive: PAIN:
medial pain or lateral pain reported based on meniscus
PART 2: Distraction: Ligament
Position: PRONE
Joint angles: Knee flexed 90 degrees
Hand placement: Stabilize distal femur with my knee. Surround distal tibia/fibula with both hands around over the malleoli and distract towards the ceiling to open the space
Motion: (?continue IR/ER) distract tibia from femur towards the ceiling
Positive: Pain indicate ligamentous injury
Bounce Home Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
examine for torn meniscus blocking extension
Position: Supine
Joint angles: fully flexed knee
Hand placement: hold above malleoli around back of gastroc and other hand in popliteal area
Motion: allow patient knee to passively extend
Positive: knee does not fully extend , rubbery end feel indicates a blockage to extension
Helfet Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
draw a dot on tibial tubercle and a dot on medial patella and look at the screw home mechanism
Torn meniscus locks the joint so you cannot do Helfet Maneuver and ER because the knee is obstructed
after this we can do the palpation along the joint line to see if there is tenderness or a sense of thickening
Wipe Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
Position: supine
Joint angles: knee extended
Motion:
- fluid is massaged across suprapatellar pouch from medial to lateral.
- Then try to move fluid from lateral to medial using a wiping action over the patella
Positive: fluid bulge inferomedially to the patella indicates joint effusion is present
Ballotable Patella = Patella Tap
Position: Joint angles: Hand placement: Motion: Results: Positive:
floating patella:
patient lie supine, knee extended
push down on patella
fluid will flow to either side and return underneath the patella causing the patella to rebound upward (large effusion)
Indentation Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
Position: Supine
positive result: Indentation on either side of patella tendon disappears with knee flexion (in normal people the indentations would not disappear)
Patellafemoral Grinding Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
precursor of Clarcke’s test: put hand in patella and compress into groove and grind it
Clarke’s Sign
Position: Joint angles: Hand placement: Motion: Results: Positive:
Position: Supine
Joint angles: knee extension
Hand placement: on patella
Motion: hold superior patella and ask patient to contract quadriceps while i push the patella into the grove
Positive: pain indicate patellofemoral dysfinction
Patella Stability Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
????
for dislocated patella
usually dislocates laterally
position: supine
joint angle: flex and then extend knee a
MEDIAL SIDE: patella moves 1cm medially
LATERAL SIDE: patella moves out 1/3 patella width laterally
Fairbank’s Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
push patella laterally and see patient reaction – apprehension test
Waldron Test
Position: Joint angles: Hand placement: Motion: Results: Positive:
detect patellafemoral arthritis
patient is standing, compress patella unilaterally on WB leg –wb on one leg only
maintain this compression as patient flexes knee as squatting–do not let patella slide up (heel of thumb on superior border of patella so that it cannot displace superiorly)
positive: pain
Patella Distraction
stand at side
use fingers to pull it up (pointers and thumbs)
can use a sink plunger
Superior Glide
for knee extension
knee 20-40 degrees flexion with towel roll
i stand inferior to knee
i use thumbs to glide the patella
can do oscillations 1,2,3,4 and sustained hold
Inferior Glide
for knee flexion
knee 20-40 degrees flexion with towel roll
i stand inferior to knee
i use thumbs to glide the patella
can do oscillations 1,2,3,4 and sustained hold
- Medial Glide
knee 20-40 degrees flexion with towel roll
i stand inferior to knee
i use thumbs to glide the patella
can do oscillations 1,2,3,4 and sustained hold
- Lateral Glide
knee 20-40 degrees flexion with towel roll
i stand inferior to knee
i use thumbs to glide the patella
can do oscillations 1,2,3,4 and sustained hold
- Inferior technique for stiffness (in position of extension)
use heel of hand and not compress patella:
—do sustained glide inferiorly in knee extension
Distraction of the tibia
sitting
20-40 degrees flexion
femur stabilized on table
longitudinal force distally
–incr ROM flexion by having position of more flexion ie 70 degrees
Anterior Glide of Tibia
improve EXTENSION
supine
knee flexed: start at 40 and progress to 90
stabilize foot sit on it
position yourself like anterior drawer test
pull tibia anteriorly
–for the last 5-10 degrees of extension I can move femur back instead of moving tibia forward
Posterior Glide of Tibia
Improve FLEXION
supine
knee flexed: start at 40 and progress to 90
stabilize foot sit on it
position yourself like posterior drawer test
push tibia posterior
can do in sitting or prone also
- Lateral Glide of Tibia
facilitates Internal Rotation and valgus/varus???
seated put end of tibia between my legs mobilize at poximal medial aspect of tibia stabilize distal femur transverse movement across laterally
Medial Glide of Tibia
facilitates External Rotation and varus /valgus???
seated put end of tibia between my legs mobilize at poximal lateral aspect of tibia stabilize distal femur transverse movement across medially
Tx of the Hypermobile Knee (hypo?)
Dorsal Glide of Femur
use a towel roll if missing last 10 degrees of flexion
Dorsal Glide of Femur
to tx hypermobile knee (hypo?)
