Apply a valgus force at 0° & 30 ° knee flexion
Knee MRI
May 14, 2018
Ankle Examination
July 2, 2018Knee Examination
Human anatomy
Muscle and tendon attachments
VMO: Vastus medialis, VL: Vastus lateralis, MPFL: medial patellofemoral ligament
MCL
LCL
Apply a varus force at 0° & 30 ° knee flexion
Knee extensor mechanism
- Straight leg raise
- If absent palpate defect.
- Ultrasound useful for pre operative planning to ascertain the tissue stump for surgical repair.
Examine hip rotation and assess femoral neck version
Hip IR & ER
Supine Gage
Traditional femoral neck anteversion test is done in prone position
Meniscus
Various meniscus tests are available and range from palpation to loading the meniscus with direct axial compression by the examiner or by the utilization of compression using the patients own body weight to generate a force in either standing or walking with varying degrees of knee flexion. The principles are based on loading the meniscus while testing in varying degrees of knee flexion ± rotational movements by a force transmission. A few common tests are highlighted.
Commonly used meniscus tests
- Palpate joint line tenderness
- McMurray test
- Thessaly test
- Apley test
Meniscus tests
The Apley test
- Position: patient in a prone position with the tested knee at 90° of flexion. The examiner holds the patient heel & applies an axial compression load while rotating the tibia on the femur.
- Positive test: + pain on axial compression
Thessaly test
- Position: Patient stands on a single leg to be tested & then flexes the knee to 20°. The clinician supports the patient by holding their outstretched hands. The patient then rotates their knee and body 3 times , both internally and externally while in a position of 20° of knee flexion.
- Positive test: + joint line pain ± click.
McMurray test
- Position: Patient is supine. The examiner holds the patients foot and flexes the patient’s hip and knee and palpating the knee joint line for a pop or click as the tibia is internally and externally rotated while extending the knee.
- Positive test: + click or pop
Duck walking
- Deep knee flexion predominantly loads the posterior horn of the meniscus and loading the meniscus in this position is used to test for posterior horn tears: Duck walking i.e. loading the meniscus in deep flexion while using the patients body weight as a force may be used to test for posterior horn tears.
- Positive test: + pain
ACL
Lachman test (View 1)
Lachman test (View 2)
Anterior Drawer Test
Anterior and posterior drawer tests: start test by first palpating the tibia in relation to the medial femoral condyle. Assess tibia position and ascertain if it is in an anatomical position before commencing with the Anterior and Posterior drawer tests.
Pivot test
Lachman test
Positive Lachman test
PCL
- Observation: posterior sag, hyperextension
- Posterior Drawer test
Anterior and posterior drawer tests: start test by first palpating the tibia in relation to the medial femoral condyle. Assess tibia position and ascertain if it is in an anatomical position before commencing with the Anterior and Posterior drawer tests.
PLC tests
Posterolateral drawer test
- Position: Supine with test knee at 90° knee flexion & 15° external rotation.
- Perform a posterior drawer & external rotatory force. Assess for éposterolateral translation.
- + test: Lateral tibia plateau moves posteriorly with a stable medial plateau.
External rotation recurvatum test
- Supine position: Hold foot and externally rotate at 0° knee extension.
- Support proximally to the knee joint with other hand and hyperextend the knee.
- Compare to contralateral side. Hyperextension indicative of PCL & PLC instability.
Reverse pivot test
- Supine position with starting knee position of 90°: Extend and at 80° knee flexion apply a valgus & externally rotation force then extend knee while applying this force.
- Compare with contralateral side
- Positive test: tibia reduces from subluxation in flexion when the Iliotiobial is a predominant knee flexor and then becomes a predominant extensor moment to the knee at end range of knee extension.
Dial test
- Supine or prone position: Hold foot and externally rotate at 30° & 90° knee flexion. Compare bilaterally.
- Dial test at 30°: positive if > 30°(average) external rotation
- Dial test at 90°: positive > 37° (average) With increasing ER at 90° combined PCL & PLC.
Dial at 30
Dial at 90
Supine dial
Comparative supine with prone dial to assess for false positive test due to antero-medial knee instability that can also causes and increase in external foot rotation. During supine dial test confirm no antero-medial instability.
Multi-ligament instability
Exclude vascular injury & assess common peroneal nerve function.
Combined ACL & PCL instability
5 months post surgery stable knee
Patellar: Q angle
Assess regional & global alignment
Factors affecting patella tracking
Patellar
Examination focus on regional & global
- Examine Hip anteversion, tibia rotation & foot position profile
- Observation: J sign
- Palpation
- Assess lateral translation
- Apprehension test
Observation
Assess lateral translation
Assess lateral translation & also quantify the degree of lateral translation.
Patellar Apprehension Test
Apply valgus force to patellar & flex from full extension. Positive test: Patient apprehend movement due to pain & patellar subluxation.
PFJ: assess Hip ROM & degree of femoral anteversion and tibia rotation/foot profile
Hip ROM
Internal & external rotation of hip joint.
Complete full hip examination to exclude referred pain from hip joint.
Gage test: Assess degree of anteversion
Prone position. Knee is placed in 90° of flexion. The examiner rotates the hip internally while palpating the greater trochanter area, until the outward most point is found in the lateral aspect of the hip (the greater trochanter is parallel to the examination couch ) = femur anteversion. Normal hip anteversion is 8°-15°.
Femoral version is defined as the angular difference between axis of femoral neck and transcondylar axis of the knee.
