Knee Practical

Question 1

One Plane Lateral Instability

Answer 1

1. Varus Stress Test With knee in slightly flexed

2. Varus Stress Test With knee in full extension

Question 2

One Plane Medial Instability

Answer 2

1. Valgus Stress Test With knee slightly flexed

2. Valgus Stress Test With knee in full extension

Question 3

One Plane Anterior Instability

Answer 3

1. Lachman Test

2. Anterior Drawer Test

Question 4

One Plane Posterior Instability

Answer 4

1. Posterior Sag Sign
2. Posterior Drawer Test
3. Reverse Lachman Test

Question 5

Anteromedial Rotary Instability

Answer 5

1. Slocum test

Question 6

Anterolatereal Rotary Instability

Answer 6

1. Slocum Test

2. Lateral Pivot Shift Test

Question 7

Posteromedial Rotary Instability

Answer 7

1. Hughston’s posteromedial drawer Test

Question 8

Posterolateral Rotary Instability

Answer 8

1. Houghston’s posterolateral drawer Test

Question 9

Squat walk

Answer 9

1. Squat and walk with feet in IR: lateral meniscus pain

2. Squat and walk with feet in ER: medial meniscus pain

Question 10

Medial Meniscal Tests:

Answer 10

1. McMurry for Medial Meniscus (valgus + ER of the tibia and extend knee)

Question 11

Lateral Meniscal Tests:

Answer 11

1. McMurry for Lateral Meniscus (varus + IR of the tibia and extend knee)

Question 12

Both Menisci together–not to discrimnate

Answer 12

1. Apley’s Test: (part 1 grinding in prone, knee flex 90 deg-part two checks ligaments)
2. Bounce Home Test (supine, knee flex drop to extend)
3. Helfet Test (dot on tibial tubercle and medial patella-screw home mechanism obstruct)

also: tender along joint line
walk with feet in IR/ER

Question 13

Tests for swelling in the knee

Answer 13

1. Wipe Test
2. Patella Tap
3. Indentation Test

Question 14

Dx for knee effusion

Answer 14

1. self noted knee swelling
2. positive ballottmemt/patella tap test

standard reference: MRI with intra-articular fluid within the infrapatellar/medial/or lateral compartment

Question 15

Tests For Plica

Answer 15

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]

Question 16

Test for Patellofemoral Dysfunction

Answer 16

1. Patellafemoral Grinding Test
2. Clarke’s Sign
3. Patella Stability Test
4. Fairbank’s Test
5. Waldron Test

Question 17

Joint Mobility Testing of the Knee: Patella

Answer 17

1. Patella Distraction
2. Superior Glide
3. Inferior Glide
4. Medial Glide
5. Lateral Glide
6. Inferior technique for stiffness (for extension)

Question 18

Joint Mobility Testing of the Knee: Tibia

Answer 18

1. Distraction of the tibia
2. Anterior Glide of Tibia
3. Posterior Glide of Tibia
4. Lateral Glide of Tibia
5. Medial Glide of Tibia
6. Treatment of Hypermobile Knee

Question 19

Varus Stress Test With knee in slightly flexed

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 19

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.

Question 20

Varus Stress Test With knee in full extension

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 20

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.

Question 21

Valgus Stress Test With knee slightly flexed

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 21

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

Question 22

Valgus Stress Test With knee in full extension

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 22

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

Question 23

Lachman Test

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 23

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

Question 24

Anterior Drawer Test

Position:
Joint angles: 
Hand placement: 
Motion: 
Results: 
Positive:

Answer 24

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

Question 25

Posterior Sag Sign Godfrey Sign ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 25

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

Question 26

Posterior Drawer Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 26

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

Question 27

Reverse Lachman Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 27

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

Question 28

Slocum test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 28

1. 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 2. 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

Question 29

Lateral Pivot Shift Test = Test of Macintosh ``` Position: Joint angles: Hand placement: Motion: Results: Positive: False negative: ```

Answer 29

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

Question 30

Hughston's posteromedial drawer Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 30

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

Question 31

Houghston's posterolateral drawer Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 31

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

Question 32

Squat with feet in IR: lateral meniscus pain

Answer 32

quick test: if put tibia in IR and squat feel pressure on lateral side = EGE test

Question 33

Squat with feet in ER: medial meniscus pain

Answer 33

quick test: if put tibia in ER and squat feel pressure on medial side

Question 34

McMurry Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 34

one for medial mensicus | one for lateral meniscus

Question 35

McMurry for Lateral Meniscus ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 35

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

Question 36

McMurry for Medial Meniscus ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 36

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

Question 37

Apley's Test: ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 37

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

Question 38

Bounce Home Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 38

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

Question 39

Helfet Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 39

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

Question 40

Wipe Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 40

Position: supine Joint angles: knee extended Motion: 1. fluid is massaged across suprapatellar pouch from medial to lateral. 2. 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

Question 41

Ballotable Patella = Patella Tap ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 41

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)

Question 42

Indentation Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 42

Position: Supine positive result: Indentation on either side of patella tendon disappears with knee flexion (in normal people the indentations would not disappear)

Question 43

Patellafemoral Grinding Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 43

precursor of Clarcke's test: put hand in patella and compress into groove and grind it

Question 44

Clarke's Sign ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 44

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

Question 45

Patella Stability Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 45

???? 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

Question 46

Fairbank's Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 46

push patella laterally and see patient reaction -- apprehension test

Question 47

Waldron Test ``` Position: Joint angles: Hand placement: Motion: Results: Positive: ```

Answer 47

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

Question 48

Patella Distraction

Answer 48

stand at side use fingers to pull it up (pointers and thumbs) can use a sink plunger

Question 49

Superior Glide

Answer 49

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

Question 50

Inferior Glide

Answer 50

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

Question 51

4. Medial Glide

Answer 51

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

Question 52

5. Lateral Glide

Answer 52

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

Question 53

6. Inferior technique for stiffness (in position of extension)

Answer 53

use heel of hand and not compress patella: | ---do sustained glide inferiorly in knee extension

Question 54

Distraction of the tibia

Answer 54

sitting 20-40 degrees flexion femur stabilized on table longitudinal force distally --incr ROM flexion by having position of more flexion ie 70 degrees

Question 55

Anterior Glide of Tibia

Answer 55

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

Question 56

Posterior Glide of Tibia

Answer 56

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

Question 57

4. Lateral Glide of Tibia

Answer 57

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 ```

Question 58

Medial Glide of Tibia

Answer 58

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 ```

Question 59

Tx of the Hypermobile Knee (hypo?)

Answer 59

Dorsal Glide of Femur use a towel roll if missing last 10 degrees of flexion

Question 60

Dorsal Glide of Femur

Answer 60

to tx hypermobile knee (hypo?)