Ortho Lower Extremity: Hip/Knee Specialized Physical Exam Tests

Question 1

Positive impingement sign (femoral acetabular impingement)

Answer 1

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)

Question 2

Trendelenburg Test

Answer 2

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)

Question 3

Anterior drawer test

Answer 3

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

Question 4

Apley’s compression test

Answer 4

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

Question 5

Ballottement sign

Answer 5

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

Question 6

Dynamic malalignment evaluation

Answer 6

Observe gait for excessive varus or valgus knee movement

Increased risk for patellofemoral pain syndrome

Question 7

Knee extension test

Answer 7

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

Question 8

Lachman test

Answer 8

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

Question 9

McMurray test

Answer 9

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

Question 10

Medial patellar plica test

Answer 10

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)

Question 11

Noble’s test

Answer 11

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)

Question 12

Ober’s test

Answer 12

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

Question 13

Patellar apprehension test

Answer 13

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)

Question 14

Patellar compression test

Answer 14

o Directly compress the patella into the trochlear groove while the leg is extended
o Positive test: pain (c/w patellofemoral pain syndrome)

Question 15

Patellar facet/retinaculum tenderness

Answer 15

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)

Question 16

Patellar glide

Answer 16

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

Question 17

Patellar grind test (Clarke sign)

Answer 17

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

Question 18

Patellar tracking

Answer 18

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

Question 19

Pivot Shift Test

Answer 19

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

Question 20

Posterior drawer test

Answer 20

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

Question 21

Thessaly test

Answer 21

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

Question 22

Valgus stress test

Answer 22

Move leg lateral to assess medial meniscus

Question 23

Varus stress test

Answer 23

Useful to determine integrity of lateral collateral ligament

Question 24

Wilson test

Answer 24

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)