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Knee examination

Observation (compare with less affected knee)

A. Ecchymosis
B. Knee Effusion with obscured landmarks
C. Previous surgical scars
D. Knee resting position
E. Quadriceps femoris muscle angle (Q Angle)

Method

A. Position patient in slight knee flexion ( 15degrees)


B. Measure angle between 2 lines
1. Line1 : Anterior Superior Iliac to patella center
2. Line2 : Tibial Tubercle to patella center

Normal Measurement

A. Men: 11 to 17 degrees
B. Women: 14 to 20 degrees (due to gynecoid pelvis)

Causes of increased Q angle

A. Knock-kneed (Genu valgum)


B. Excessive Femoral Anteversion
C. Medial tibial torsion
D. Laterally positioned tibial tuberosity
E. Tight lateral retinaculum
F. Weakness of vastus medialis oblique
G. High riding patella (patella alta)

Risks associated with increased Q angle

Patellar subluxation

F. Quadriceps muscle atrophy


1. Often on side of ligamentous injury

Normal Range of Motion

A. Flexion: 130 degrees


B. Extension: 10 degrees above horizontal plane
Anterior Cruciate Ligament (ACL) Stability Tests

A. Lachman's Test (most sensitive)

Efficacy

A. Lachman's Test is most sensitive test for ACL rupture


B. Likelihood ratio
1. Positive Test: 42 (very predictive)
2. Negative Test:0 .1

Technique: Patient position

A. Knee in 10 to 20 degrees flexion

Technique: Examiner position

A. Non-dominant hand
1. Stabilizes distal femur
B. Standard Dominant hand positioning
1. Grasps back of proximal tibia posteriorly
a. Hold slightly below popliteal space
2. Place Thumb over joint line anterolaterally
a. Apply slightly above tibial plateau
b. Increases sensitivity for joint laxity
C. Alternate position for larger thigh (difficult to hold)
1. Prop knee up in10 - 20degrees flexion
a. Pillow in popliteal fossa
b. Allow leg to over edge of table
2. Technique
a. Use both hands, apply fingers behind
proximal tibia
b. Apply thumbs to either side of tibial
plateau

Technique: Test

A. Pulling proximal tibia anteriorly and posteriorly


B. Compare both sides for end-point laxity

Interpretation: Positive Test for ACL rupture

A. Lax endpoints on anterior translation


B. Knee Anterior Drawer Test
C. Pivot Shift Test (MacIntosh Test)

Indications

A. Assessment for Anterior Cruciate Ligament


Rupture

Technique

A. Patient lies in lateral decubitus position


1. Affected knee extended
2. Affected Tibia internally rotated
B. Examiner
1. Apply valgus stress to knee (push
from lateral side)
2. Flex knee

Interpretation: Positive Test for ACL rupture

A. Clunk felt at 30 degrees knee flexion

Posterior Cruciate Ligament (PCL) Tests

A. Knee Posterior Drawer Test

Technique

A. Patient supine
1. Hips flexed to 45 degrees
2. Knees flexed to 90 degrees
3. Feet flat on table
B. Examiner sits on patients feet to fix in place
1. Hold lower leg above calf with both
hands
2. Apply sudden firm pull forward
(Anterior Drawer)
3. Apply sudden firm push back
(Posterior Drawer)

Interpretation: Positive Test

A. Anterior Drawer: Endpoint laxity suggests


ruptured ACL
B. Posterior Drawer: Endpoint laxity suggests
ruptured PCL
B. PCL Sulcus Test

Technique

A. Patient Position
1. Patient sits with knees flexed at 90
degrees
2. Legs hanging freely over edge of
exam table
B. Examiner
1. Palpate area between tibial plateau
and femur
2. Normally space is minimal
a. Tibia and femur are well
approximated

Interpretation: Positive Test Suggests PCL


rupture

A. Space widened with sulcus between tibia and


femur

C. PCL Sag Test

Technique

A. Patient Position
1. Patient supine as if sitting in a
horizontal chair
a. Thighs at 90 degrees
b. Knees at 90 degrees
B. Examiner
1. Supports legs by holding ankles
2. Observe sag as tibial plateau sinks
below patella

Interpretation: Positive Test Suggests PCL


rupture

A. Increased sag is associated with PCL Tear


Collateral ligament evaluation

A. Knee Valgus Stress Test (Medial collateral ligament)


B. Knee Varus Stress Test (Lateral collateral ligament)

Patient Position

A. Patient lies supine on table


B. Lower thigh rests on table edge, leg hangs
off table

Technique

A. Perform each stress in two positions


1. Knee in full extension
2. Knee in 30 degrees of flexion
B. Stabilize lower thigh with one hand
C. Apply gentle stress at patient's ankle or foot
1. Valgus stress tests medial collateral
ligament
2. Varus stress tests lateral collateral
ligament
D. Repeat test with gentle rocking motion

Precautions: Varus Stress Test

A. Varus Stress Test may give false positive


result
1. Femur rolls externally if not
supported
2. Slight knee flexion may allow for
laxity
B. Stabilize ipsilateral ankle to isolate knee
1. Sit on edge of table
2. Patient's ankle rests on examiner's
upper knee

Interpretation: Positive Test implies Instability

A. See Ligamentous Sprain for laxity grading


B. Laxity on Varus stress suggests knee LCL
Tear
C. Laxity on valgus stress suggests knee MCL
Tear
Mensicus Evaluation

A. McMurray's Test

Technique

A. Patient lies supine


1. Knee flexed to 45 degrees
2. Hip flexed to 45 degrees
B. Examiner braces lower leg
1. One hand holds ankle
2. Other hand holds knee
C. Medial meniscus assessment
1. Assess for pain on palpation
a. Palpate medial joint line with knee
flexed
2. Assess for "click" suggesting meniscus
relocation
a. Apply valgus stress to flexed knee
b. Externally rotate leg (toes point
outward)
c. Slowly extend the knee while still in
valgus
D. Lateral meniscus
1. Repeat above with varus stress and internal
rotation

Interpretation: Positive Test suggests Meniscal Injury

A. "Click" heard or palpated on above maneuvers


B. Joint line tenderness on palpatio

B. Apley's Compression Test and Apley's Distraction Test

Technique

A. Patient position
1. Patient lies prone on examining table
2. Testing leg flexed to 90 degrees
B. Compression Test
1. Lean on patient's foot, applying pressure to
heel
a. Compresses tibia into femur
2. Rotate tibia internally and externally on
femur
C. Distraction Test
1. Kneel gently on back of patient's thigh to
stabilize
2. Apply traction to leg pulling tibia from
femur
3. Rotate tibia internally and externally

Interpretation

A. Positive Compression Test suggests mensical injury


1. Pain with compression test (not with
distraction)
B. Positive Distraction Test suggests ligament injury
1. Knee pain with compression and distraction
test

C. Bounce Test

Technique

A. Patient lies supine with legs extended


B. Examiner holds ankle slightly elevated over
table
C. Examiner holds knee slightly flexed with other
hand
D. Examiner releases hold on knee
1. Allows knee to fall passively into
extension

Interpretation: Positive Test suggests meniscal


tear

A. Knee pain when knee falls into extension

Standing evaluation

A. Balanced weight on each leg


B. Genu Varum or genu valgum deformity
C. Gait analysis
D. Patella baja or patella alta deformity
E. Hip, Knee, and ankle alignment