Knee

Question 1

Knee AROM

Answer 1

Flexion = 120-135
Extension = 0-15
Medial Tibial Rotation = 20-30
Lateral Tibial Rotation = 30-40

Question 2

Knee PROM

Answer 2

Tissue stretch for all

Question 3

Knee Capsular Pattern

Answer 3

Flexion and Extension

Question 4

Thessaly Test

Answer 4

• Purpose:
– Test for meniscal injury

• Procedure:
– Patient is standing
– The practitioner stands in front of the patient and supports the patient by holding his or her
outstretched hands
– The test procedure is initially performed on the patient’s normal knee for training purposes
and to appreciate a positive finding in the symptomatic knee when compared to a normal
knee
– While the patient stands flat-footed on the floor and flexes the knee to approximately 20°
– The patient then rotates his or her knee and body, internally and externally, three times,
keeping the knee flexed

• Indication of Positive:
– A positive test is indicated and recorded when patients experienced medial or lateral joint line
discomfort
– The patient may also report a sense of locking or catching of the knee

Question 5

McMurray’s Test

Answer 5

• Purpose:
– To assess for meniscal injuries of the knee

• Procedure:
– Patient is supine with knee flexed maximally
– The practitioner stands adjacent to the test knee
– Part 1: The examiner externally rotates the foot and extends the knee whiles palpating the
medial joint line and applying slight valgus pressure
– Part 2: The examiner then starts again from the flexed position and extends the knee whilst
internally rotating the patients foot, palpating the lateral joint line and exerts a slight varus
pressure

• Indication of a Positive:
– Pain and crepitation
– External rotation = medial meniscus*
– Internal rotation = lateral meniscus*
– * = Be aware of the paradoxical phenomenon described by Kim et al.

Question 6

Modified McMurray’s Test

Answer 6

• Purpose:
– To assess for meniscal injuries in the knee

• Procedure:
– The patient is supine with the knee flexed maximally
– The examiner stands adjacent to the test leg
– Part 1: The examiner applies a valgus force, externally rotates the foot and performs a half-moon
rotation
– Whilst the valgus force and flexion is maintained the examiner internally rotates the foot and
performs a half moon rotation
– Part 2: The examiner then flexes the knee and applies a varus force to the knee and repeats the half
moon rotations first with external rotation, and then again with internal rotation
– The examiner palpates the joint line throughout the procedure

• Indication if positive test:
– Pain about the joint lines +/- a click indicates meniscus injury

Question 7

Apley’s Test

Answer 7

• Purpose:
– To assess for ligament and meniscal injury of the knee

• Procedure:
– The patient lies in the prone position with the knee flexed to 90 degrees
– The practitioner stands adjacent to the involved knee
– The patient’s thigh is anchored by the examiners knee
– Part 1: The examiner medially and laterally rotates the patient’s tibia combined with
distraction
– Part 2: The process (internal and external rotation) is then repeated with compression
instead of distraction

• Indication of a Positive:
– If rotation plus distraction is more painful or shows increased rotation relative to the
normal side, the lesion is probably ligamentous
– If the rotation plus compression is more painful or shows decreased rotation relative to
the normal side, the lesion is probably a meniscus injury

Question 8

Bounce Home Test

Answer 8

• Purpose:
– To assess for meniscal injury of the knee

• Procedure:
– The patient lies in the supine position
– The examiner stands at the caudal end of the couch
– The practitioner cups the patient’s heel
– The patients knee is then flexed and passively and slowly allowed to extend (or bounce) downward with the force
of gravity
– The examiner palpates the quality of the end feel using the heel contact

• Indication of Positive:
– Lack of extension
– ‘Rubbery’ end feel (Springy block)
– Indicates meniscus pathology

• Notes:
– The unaffected leg is tested first and then compared to the affected leg
– If the test leg is allowed to extend quickly a sharp, joint line pain which radiates up or down the leg may be
produced which is also indicative of meniscal injury

Question 9

Mediopatellar Plica Test

Answer 9

• Purpose:
– To assess for a mediopatellar plica in the knee

• Procedure:
– The patient lies in the supine position with the knee flexed to 30°
– The examiner stands adjacent to the affected leg
– The examiner then contacts the lateral aspect of the patient’s patella and moves the patella medially
– The patient is then asked to contract the quadriceps while the practitioner holds the patellar medially

• Indication of a Positive Test:
– Pain about the medial plica which is located about the medial femoral condyle
– The patient may complain of a pain or a click as the patellar is moved medially
– Pain may be exacerbated when the patient contracts the quadriceps with the patella fixed in the medial
position

• Note:
– Not all patients have a medial patellar plica

Question 10

Valgus Stress Test

Answer 10

• Purpose:
– To assess for single plane medial instability, indicating that the tibia moves away from the femur
(i.e. gaps excessively) at the medial joint line
– Potential damage to the MCL, posteromedial capsule, ACL, and PCL

• Procedure:
– The patient is supine on the examination table
– The examiner stands adjacent to the patient’s test knee
– The examiner applies a valgus stress at the knee whilst stabilising the ankle and leg
– The test is first performed in full extension and then flexed 20-30 degrees

• Indication of a Positive Test:
– Laxity +/- Pain
– One plain medial instability:
• MCL injury

• Note:
– The unaffected leg is tested first
– Laxity displayed in full extension is classified as a major disruption, one or more of the rotary
instability tests may also be positive in this case

Question 11

Varus Stress Test

Answer 11

• Purpose:
– To assess for single plane lateral instability, indicating that the tibia moves away from the femur (i.e. gaps
excessively) at the lateral joint line
– Potential damage to the LCL, fibular collateral ligament, posterolateral capsule, ITB, ACL, and PCL

• Procedure:
– Patient is supine on the examination table
– The practitioner stands adjacent to the medial aspect of the test knee
– The practitioner applies a varus stress at the knee whilst stabilising the ankle and leg
– The test procedure is first performed at full extension and then flexed to 20-30 degrees

• Indication of a Positive Test:
– Laxity +/- Pain
– One plane lateral instability:
• LCL injury

• Notes:
– The unaffected leg is tested first
– Laxity displayed in full extension is classified as a major disruption subsequently one or more of the
rotary instability tests may also be positive in this case

Question 12

Anterior Draw Test

Answer 12

• Purpose:
– To assess for single plane anterior instability

• Procedure:
– The patient lies supine with the affected knee flexed to 90 degrees, the hip flexed to 45 degrees with
the hamstrings relaxed
– The patient’s foot is stabilised on the table via the examiner sitting on the patient’s forefoot in a neutral
position
– The examiner contacts the patients tibia with a bilateral contact
– The tibia is then drawn forward relative to the femur
– The amount of displacement/movement is assessed by the examiner
• Indication of a Positive Test:
– The normal amount of movement is approximately 6mm
– Laxity
– One plane anterior instability
• ACL Injury

• Notes:
– The unaffected leg is tested first
– The start position is very important, a positive sag sign will give false positives on the anterior
drawer test
– Practitioners should also note the quality of the forward translation

Question 13

Lachman Test

Answer 13

• Purpose:
– To test for single plane anterior instability

• Procedure:
– The patient is supine
– The examiner stands adjacent to the test leg
– The examiner holds the patients knee in approximately 30° flexion
– The examiner’s outside hand stabilises the femur whilst the inside hand stabilises the tibia
– The examiner moves the tibia anteriorly relative to the femur
– The amount of displacement/movement is assessed by the examiner

• Indication of a Positive Test:
– Laxity
– Mushy or soft end feel
– One plan anterior instability
• ACL injury

• Notes:
– The unaffected leg is tested first
– Practitioners should also note the quality of the forward translation
– Practitioners should be aware that a meniscal tear may block the forward translation of the tibia
relative to the femur

Question 14

Slocum’s Test

Answer 14

• Purpose:
– To assess for anterolateral and anteromedial rotary instability

• Procedure:
– The patient lies supine on the examination table with knee flexed to 90° hip flexed to 45°
– The examiner stands at the caudal end of the examination table

– Part 1: The patient’s foot is held on the table by the examiners body by sitting on the patient’s
forefoot in 30° medial rotation
– The examiner contacts the patients tibia with a bilateral contact and the tibia is then drawn
forward relative to the femur

– Part 2: The patient’s forefoot/tibia is then laterally rotated 15° and the tibia is drawn forward
– The available movement along with the quality of the movement is assessed by the examiner

• Indication of Positive:
– Laxity
– Part 1: Anterolateral instability:
• ACL Injury
– Part 2: Anteromedial instability:
• MCL

• Notes:
– The unaffected leg is tested first
– Over rotation of the tibia will result in false negatives

Question 15

Lateral Pivot Shift Test

Answer 15

• Purpose:
– To assess for anterolateral rotary instability

• Procedure:
– The patient lies supine with the hip both flexed and adducted 30° and relaxed in slight medial rotation (20°)
– The examiner holds the patient’s foot with one hand while the other hand is placed at the knee, holding the leg in slight
medial rotation. This is done by placing the heel of the hand behind the fibula and over the lateral head of the
gastrocnemius muscle.

– Part 1: The tibia is medially rotated, and a valgus force is applied causing it to subluxate anteriorly as the knee is taken
into extension

– Part 2: The leg is then flexed, and at approximately 30° to 40° the tibia reduces backward
– The examiner palpates for this tibiofemoral displacement

• Indication of Positive:
– Tibiofemoral displacement – anterior subluxation in extension, tibia “jog” backwards in flexion
– The patient may feel a giving way as the tibia relocates during the flexion phase of the manoeuvre (Part 2)
– Anterolateral rotary instability
– ACL Injury

• Note:
– The iliotibial band must be intact for the test to work
– The ITB acts as both a guide for extension and flexion. The flexion action of the ITB is what causes the
relocation of the tibia during flexion
– This test mimics the normal anterior-subluxation reduction phenomenon that occurs during the normal gait
cycle in an individual with a torn ACL

Question 16

Sag Sign

Answer 16

• Purpose:
– To assess for posterior cruciate ligament damage

• Procedure:
– The patient lies supine with the hip flexed to 45 degrees and knee flexed
to 90 degrees
– The examiner observes the position of the tibia in relation to the femur

• Indication of a Positive Test:
– A drop back or sag sign (posterior displacement of the tibia in relation to
the femur)
– One plane posterior instability of the knee
• PCL injury

Question 17

Posterior Draw Test

Answer 17

• Purpose:
– To assess for single plane posterior instability

• Procedure:
– The patient is supine on the examination table
– The patient’s knee is flexed to 90° and hip flexed to 45°
– The patient’s foot is held on the table by the examiners body by sitting on the patient’s
forefoot in a neutral position
– The examiner contacts the patient’s tibia using a bilateral contact
– The tibia is then moved posteriorly relative to the femur
– The magnitude and quality of the movement is assessed by the examiner

• Indication of Positive:
– Laxity
– One plane posterior instability
• PCL Injury

• Notes:
– The unaffected leg is tested first

Question 18

Hughston’s Test

Answer 18

• Purpose:
– To assess for posteromedial and posterolateral instability

• Procedure:
– The patient lies supine with knee flexed to 90° hip flexed to 45°
– The patient’s foot is held on the table by the examiners body by sitting on the patient’s forefoot in a medially rotated position
30°
– The examiner contacts the patients tibia with a bilateral contact

– Part 1: The tibia is then moved posteriorly relative to the femur

– Part 2: The tibia is then rotated laterally (15°) and the process is repeated
– Movement is assessed by the examiner

• Indication of Positive:
– Laxity
– Part 1:
• Posteromedial instability
• PCL Injury
• Poster medial corner injury
– Part 2:
• Posterolateral instability:
• PCL Injury
• Posterior lateral corner injury

• Notes:
– This test may also be done with the patient sitting with the knee flexed over the edge of the examining table. Rotary and
posterior forces are applied in the same fashion as the supine version of the test.

Question 19

External Rotation Recurvatum Test

Answer 19

• Purpose:
– To assess for posterolateral rotary instability

• Procedure:
– The patient lies supine with the lower limbs completely relaxed
– The examiner gentle grasps the big toe of one limb and lifts the foot off the examination table whilst
applying slight A-P pressure on the distal thigh
– The patient’s knee is allowed to fall into full passive extension
– The examiner observes then the position of the knee joint and amount of genu recurvatum
– The procedure is repeated on the opposite side

• Indication of Positive:
– The affected knee goes into relative hyperextension, varus deformity and the tibial tuberosity on the involve
side rotates laterally
– Posterolateral instability:
• PCL and posterolateral corner injury

• Notes:
– The affected knee has the appearance of a relative genu varum in extension
– This tests may give high false negative in cases of combined ACL tear and posterolateral instability

Question 20

Fluctuation Test

Answer 20

• Purpose:
– To asses for swelling/joint effusion around the knee

• Procedure:
– The patient is supine on the examination table
– The practitioner stands adjacent to the test leg
– The examiner places the palm of one hand over the suprapatella pouch and the palm of the
other hand anterior to the joint line with the thumb and index finger just beyond the margins
of the patella
– By pressing down with one hand and then the other, the examiner may feel the synovial fluid
fluctuate under the hands and move from one hand to the other

• Indication of a Positive Test:
– Visible or palpable fluctuating fluid which indicates joint effusion

• Note:
– In cases of swelling, the knee assumes its resting position of 15-25° of flexion. This position
allows the maximum fluid holding capacity of the synovial cavity

Question 21

Wipe test

Answer 21

• Also known as the ‘stroke test’, ‘brush test’, or ‘bulge test’

• Purpose:
– To asses for swelling/joint effusion around the knee

• Procedure:
– The patient is supine on the examination table
– The practitioner stands adjacent to the test leg

– Part 1: Starting below the joint line at the medial side of the patella, the practitioner strokes superiorly towards the
suprapatellar pouch three times using the fingers and the palms

– Part 2: the practitioner then strokes down the lateral side of the patella from the suprapatellar pouch to just below the joint line

• Indication of a Positive Test:
– A wave of fluid passes to the medial side of the joint and bulges just below the medial distal portion or border of the patella
– The normal volume of synovial fluid is 1-7ml
– This test will highlight instances 4-8ml of extra fluid within the knee

• Note:
– In cases of swelling, the knee assumes its resting position of 15-25° of flexion.
– This position allows the maximum fluid holding capacity of the synovial cavity

Question 22

Clarke’s Sign (Patellar Grind Test)

Answer 22

• Purpose:
– To assess for the presence of patella-femoral pain syndrome (PFPS)

• Procedure:
– The patient is supine on the examination table
– The practitioner stands adjacent to the test leg
– The examiner presses down slightly proximal to the upper pole or base of the patella with the web contact of the hand as the
patient lies relaxed with the knee extended (The ankle of the patient’s test leg may need to be supported to maintain the leg in
relaxed extension
– The patient is then asked to contract the quadriceps muscle while the examiner maintains the downward pressure
– The test is performed in several positions; full extension, 30° flexion, 60° flexion and 90° flexion

• Indication of a Positive Test:
– Retro-patella pain indicating PFPS
– An inability of the patient to maintain the quadriceps contraction

• Notes:
– The practitioner must be careful not to apply too much pressure as this may result in false positives. Instead the practitioner
should apply pressure incrementally
– Some authors suggest pressing down on the patella itself during the test

Question 23

Lateral Pull Test

Answer 23

• Purpose:
– To assess for patello-femoral arthralgia/PFPS

• Procedure:
– The patient lies supine with the knee extended
– The examiner stands adjacent to the patient’s test leg in a position to view the patella
movements
– The patient is then asked to contract the quadriceps while the examiner watches the
movement of the patella

• Indication of Positive:
– Lateral patella over-pull indicating PFPS
– Excessive lateral patella movement

• Notes:
– Normally the patella moves superiorly or superiorly and lateral in equal proportions
– Inexperienced practitioners need to become familiar with normal patella movement

Question 24

Fairbank’s Apprehension Test

Answer 24

• Purpose:
– To assess for dislocation/instability of the patello-femoral joint

• Procedure:
– The patient lies in the supine position with the quadriceps muscle relaxed and the knee
flexed to 30°
– The examiner sits medial to the patient’s test leg
– The examiner contacts the medial aspect of the patella and carefully and slowly pushes the
patella laterally
– The practitioner observes for patient apprehension and/or quadriceps contraction

• Indication of Positive:
– The patient feels apprehensive as the patella is moved laterally
– If the patient feels the patella is going to dislocate, the patient will contract the quadriceps
muscle to bring the patella back to a more neutral position
– Indicates patello-femoral instability

• Note:
– The practitioner should discontinue application of the lateral force once
apprehension and/or quadriceps contraction has been elicited

Question 25

Wilson Test

Answer 25

• Purpose:
– To assess for osteochondritis dissecans (OCD) of the knee

• Procedure:
– The patient is supine
– The practitioner stands adjacent to the patient’s test leg

– Part 1: The practitioner flexes the patient’s knee to 90° and internally rotates the tibia
– The practitioner then extends the patient’s knee while maintaining the internal rotation of the tibia
– The patient is asked to report if and when they experience pain

– Part 2: If the patient reports pain with Part 1 of the test, the practitioner repeats the procedure this time with the tibia laterally rotated
– This should either eliminate the patient’s pain or delay the onset of the pain into extension

• Indication of Positive:
– Pain during the performance of Part 1, usually comes on at approximately 30° of flexion and is relieved by Part 2 of the test
– Indicating OCD of the medial femoral condyle

• Notes:
– This test can also be performed in the sitting position and/or with active extension of the knee

Question 26

Noble’s Compression Test

Answer 26

• Purpose:
– To assess for iliotibial band friction syndrome

• Procedure:
– The patient is supine on the examination table
– The practitioner stands adjacent to the test leg
– The examiner flexes the patients hip and knee to 90°
– The practitioner then applies thumb pressure to the lateral femoral condyle
– The patient’s knee is then passively extended while maintaining the pressure at the
lateral femoral condyle

• Indication of Positive:
– At roughly 30° of flexion the patient describes severe pain about the lateral femoral
condyle which is similar to the pain felt on activity indicating ITB friction syndrome
– Pain indicates a positive test