Ortho Lower Extremity: Hip/Knee Specialized Physical Exam Tests Flashcards
Positive impingement sign (femoral acetabular impingement)
Provocative maneuver which involves placing the hip in maximal flexion, adduction, and internal rotation
Pain with this maneuver is considered a positive impingement sign and can indicate femoral acetabular impingement (hip impingement)
Trendelenburg Test
Useful to evaluate hip abductor strength (primarily the gluteus medius)
Stand behind the patient to observe the level of the pelvis as you instruct the patient to stand on one leg
With normal hip abductor strength, the pelvis will remain level
Postivie test: Pelvis drops below the level on the opposite side (occurs d/t inadequate hip abductor strength)
Anterior drawer test
Assesses ACL
Patient lies supine and knee is flexed at 90 degrees
Proximal tibia is gripped with both hands and pulled anteriorly (checking for anterior translation)
Clinician often sits on foot while performing the test to provide stability
Positive test: anterior translation compared to the unaffected knee
Apley’s compression test
Useful to assess meniscal injury
Knee is flexed to 90 degrees
Clinician can stabilize the patient’s thigh with a knee or hand
Press the patient’s heel directly toward the floor while internally and externally rotating the foot (this compresses the meniscus b/w the tibial plateau and the femoral condyles)
Positive test: focal pain elicited by compression
Ballottement sign
Use both hands and milk the synovial fluid into the center of the knee from all 4 quadrants
With the index finger, the patella is forcibly snapped down against the femur
Moderate effusion a/w clicking or tapping sensation
Dynamic malalignment evaluation
Observe gait for excessive varus or valgus knee movement
Increased risk for patellofemoral pain syndrome
Knee extension test
With patient supine, starting with the knee at 90 degrees of flexion, the patella is forced medially while the examiner internally rotates the lower leg and then slowly extends the knee
Positive test: patient’s pain and popping are reproduced b/w 45-60 degrees of flexion
Lachman test
Useful to assess ACL
Place the knee in 30 degrees of flexion and then stabilize the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand (intact ACL will limit anterior translation and provide a distinct endpoint)
Positive test: increased translation compared with the uninjured knee and a vague endpoint suggests ACL injury
McMurray test
Used to assess knee menisci
Patient lies supine and the knee is flexed to maximum pain free position
Clinician holds the leg in that position while externally rotating the foot and then gradually extending the kneE (while maintaining the tibia in external rotation)
This maneuver stresses the medial meniscus and often elicits a localized medial compartment click and/or pain in patients with a tear of the posterior horn of the medial meniscus
Maneuver can be repeated whle rotating the foot internally to stress the lateral meniscus
Medial patellar plica test
Useful to assess plica syndrome
Patient lies in supine position
Apply pressure with the thumb over the inferior and medial aspect of the patellofemoral joint with the aim of interposing the medial plica b/w the medial patellar facet and the medial condyle
While maintaining this pressure, the knee is passively flexed from 0-90 degrees
Positive test: medial pain is reproduced b/w 30-45 degrees (may be associated clicking or popping sensation)
Noble’s test
Useful to assess IT band syndrome
Patient lies supine
Clinician’s thumb is placed over the lateral femoral epicondyle
Patient repeatedly flexes and extends knee
Positive test: pain when knee flexed (often worse at 30 degrees)
Ober’s test
oUseful to assess IT band syndrome
o Patient lies on side (unaffected side down)
o Flex unaffected hip and knee to 90 degrees
o Flex affected knee to 90 degrees and abduct and hyperextend the ipsilateral hip while stabilizing the pelvis
o Thigh is then slowly lowered as far as possible
o Inability of the extremity to drop below horizontal to the level of the table indicates a tightness of the tensor fascia lata and IT band
o Suggestive of IT band syndrome if difficult adduction of affected knee or lateral knee pain on attempted adduction
Patellar apprehension test
o Useful to detect patellar instability
o Patient lies supine on the exam table with knee in 20-30 degrees of flexion and quads relaxed
o Examiner carefully glides the patella laterally (normally patella should be able to move laterally before reaching an end point)
o Positve test: Absence of a firm end point w/ lateral patellar movement and patient becomes apprehensive and/or contracts the quadriceps to avoid further lateral displacement of the patella (apprehension sign)
Patellar compression test
o Directly compress the patella into the trochlear groove while the leg is extended
o Positive test: pain (c/w patellofemoral pain syndrome)
Patellar facet/retinaculum tenderness
o With patient’s knee in full extension and the quadriceps relaxed, displace the patella laterally and palpate the lateral facet (undersurface) through the retinaculum and synovium
o Repeat on medial side
o Positive test: pain/tenderness (c/w patellofemoral pain syndrome)
Patellar glide
o With knee extended and quadriceps relaxed, manually displace the patella laterally and medially
o Translation < ¼ of the patella’s width signifies a tight retinaculum while translation of ¾ of patellar width signifies a hypermobile patella
o Useful to assess patellofemoral instability
Patellar grind test (Clarke sign)
o Assesses for cartilage degeneration under the patella
o Patient is supine with knee in extended position
o Examiner pushes the patella distally and asks the patient to contract the quadriceps
o Patella should glide smoothly cephalad
o Positive test: pain and crepitation on patellar movement
Patellar tracking
o Palpate the patella as the patient flexes and extends the knee (patella normally moves in a gentle arc from a relatively lateral position when the knee is extended to a more medial position during early flexion and then back to a relatively lateral position as flexion continues)
o If patellar instability is present, normal arc of movement is increased and may make a inverted “J-shaped” motion
J sign: Patella moves laterally > 1 cm as the knee nears full extension
Pivot Shift Test
o Can be difficult to perform in awake patient due to guarding
o Sensitive only in a fully relaxed and cooperative patient
o Positive test is highly specific (but insensitive) for ACL rupture
o May be inaccurate if a complete tear of the MCL exists
o Used to assess dysfunction in the knee with ACL deficiency
o Patient is supine and the knee is placed in full extension and then slowly flexed while the examiner applies a valgus stress and internal rotation stress
o Positive test: subluxation will occur at 20 degrees to 40 degrees of knee flexion
Posterior drawer test
Useful to assess posterior cruciate ligament (PCL)
Similar to anterior drawer test except examiner pushes tibia away from himself/herself
Positive test: tibia slides backward on the femur
Thessaly test
o Useful to assess meniscal injury
o Attempts to simulate loading forces placed upon the knee
o Have patient hold an examiner’s hand and then stand on one leg with the knee flexed to 20 degrees
o Have patient internally and externally rotate their knee
o Positive test: Pain or a locking or catching sensation
Valgus stress test
Move leg lateral to assess medial meniscus
Varus stress test
Useful to determine integrity of lateral collateral ligament
Wilson test
o Patient sits on edge of exam table
o Grasp foot and turn it inward so the anterior tibia rotates toward opposite leg
o Instruct patient to extend the affected leg until painful
o Can be useful to assess osteochondritis dissicans (if patient experiences pain when leg reaches 30 degrees of flexion and is relieved when leg is rotated back to normal position, suggestive of osteochondritis dissecans)
