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325 AH Knee Injuries Laboratory I. History A. Mechanism of Injury 1. Direct Force a. Contusion (1) Quadriceps Muscle - particularly prone to develop hematoma or myositis ossificans (2) Hamstring Muscle, Popliteus (3) Capsule - may lead to synovitis or hemarthrosis, repeated blow may lead to chronic synovitis (4) Bursa - bursitis (5) Adductor Muscles - rare (6) Patellar or Tibial Periosteum - periosteal contusion, very painful b. Fractures (1) Patella - may be fractured transversely, longitudinally, or in stellate pattern (2) Femur, Fibula, Tibia - most commonly in shaft, extreme force, high speed contact (3) Osteochondral - more common in 16-18 year olds, result from compression & rotary forces or patella dislocation (4) Chondral - usually weight-bearing surface of condyles, associated with ACL tears, more common in skeletally mature (5) Epiphyseal - peak age is 12 to 15 in boys & 10-13 in girls c. Tibial Anterior or Posterior Shift - posterior forces may disrupt PCL, possibly arcuate ligament complex and/or posterior oblique ligament. Anterior forces may injure ACL, and medial or lateral capsular ligaments, severe blow may dislocate knee & result in popliteal artery disruption. d. Force to Anteromedial Tibia - can cause posterolateral rotary instability due to arcuate-popliteus complex injury (arcuate ligament, fibula collateral ligament, popliteal tendon, posterior 1/3 of capsule) e. Force to Medial Knee - medial tibial condyle fx or dislocation, fibula collateral f. Force to Lateral Knee - lateral tibial plateau fx, tibial collateral sprain g. Force to Fibula - peroneal nerve damage, sprain or dislocation of superior tibiofibular joint, fx fibula 2. Overstretch a. Valgus Stress - tibial collateral, medial capsule ligament, medial & lateral meniscus, ACL, femoral epiphysis, posterior oblique ligament, posterior capsule (medial portion), PCL (rare) b. Varus Stress - fibula collateral ligament, posterolateral capsule, iliotibial band, arcuate-popliteus complex, biceps femoris tendon, peroneal nerve ACL, PCL c. Knee Flexion & Tibial Medial Rotation -posterolateral capsule, ACL, popliteus tendon, arcuate ligament, fibular collateral ligament, lateral femoral condyle, lateral coronary ligament, osteochondral fx of lateral femoral condyle and uncommonly: iliotibial band, biceps femoris, & lateral meniscus d. Knee Flexion & Tibial Lateral Rotation - posteromedial capsule, tibial collateral ligament, coronary ligament, pes anserine tendons, ACL, medial meniscus, osteochondral fx of medial femoral condyle, medial coronary ligament. e. Lateral Rotation of the Tibia with Valgus Force - medial meniscus, medial capsule, tibial collateral, posterior oblique ligament, ACL f. Deceleration with a Sudden Twist - ACL g. Knee Hyperextension - posterior capsule, ACL, PCL, fibula collateral, tibial collateral, arcuate ligament, oblique popliteal ligament, fat pad impingement, hamstring muscles, gastrocnemius muscles h. Knee Hyperflexion - PCL, posterior horns of medial & lateral menisci 3. Sudden Change of Direction a. Patellar Dislocation - medial retinaculum, VMO avulsion, medial capsule, hemarthrosis, medial ridge of patella osteochondral fx, osteochondritis dissecans of patella 4. Forceful Contraction - muscles, most commonly hamstrings & quadriceps 5. Overuse a. Running Knee Problems (1) Patellar Chondromalacia - begins with patellar malalignment, softening & eventual degeneration of cartilage & subchondral bone (2) Patellar Malalignment Syndrome (Patellofemoral Pain Syndrome) - predisposing factors include: flat shaped patella, patella alta, increased Q angle, genu valgus, femoral anteversion, weak VMO, tight vastus lateralis, L3 dysfunction, tight rectus femoris, anterior pelvic tilt, overpronation, internal tibial torsion, tight lateral retinaculum, tight iliotibial band, asynchronous quadriceps muscle firing, weak gluteus medius (3) Iliotibial Band Friction Syndrome - most common in varus knee alignment, rigid cavus foot, prominent lateral femoral epicondyle, tight iliotibial band (4) Infrapatellar Tendonitis (5) Popliteus Tendonitis (6) Pes Anserine Bursitis, Medial and Lateral Gastrocnemius Bursitis (7) Synovitis - can occur secondary to internal derangement such as cartilage tears, osteochondritis, ligamentous instability b. Jumping Knee Problems (1) Patellar Tendonitis - most commonly in late adolescence to age 40 at inferior patella pole, after age 40 more common at base of patella, both are often associated with patella malalignment, patella alta, excessive pronation (2) Sinding-Larsen-Johansson Disease - traction apophysitis of distal patella pole with calcification in avulsed portion of patella tendon, associated with tight rectus femoris (3) Osgood Schlatter Disease - traction apophysitis of tibial tubercle, associated with tight rectus femoris & patella alta c. Swimming Knee Problems (1) Medial Collateral Ligament - due to extreme external rotation with flexion & valgus force d. Squatting Knee Problems - progressive load on menisci 6. Chronic a. repeated synovitis b. bursitis c. repeated patella subluxation/dislocation d. chondromalacia e. recurring lateral pivot shift f. chronic hamstring strains g. chronic adductor strains h. chronic tendonitis (patellar, hamstring, popliteal) 7. Reenacting the Mechanism - determine body position, leg position, foot position, direction of forces B. Pain 1. Location a. Local Pain - specific sites of local pain indicate involved structures b. Referred Pain (Somatic) - hamstring strain may cause pain down entire back of leg, osteochondral fx can cause aching in entire femur, chondromalacia refers pain to retropatellar area and medial joint line, slipped capital femoral epiphysis refers pain to knee c. Radiating Radicular Pain (Nerve Root) - L4, L5 to lower leg dermatomes, S1 to posterior thigh, L3, L4 to anterior thigh 2. Onset of Pain a. Immediate - usually indicates a more severe injury b. 6 to 12 Hours After Injury - usually a less severe problem such as synovial swelling 3. Type of Pain a. Sharp - skin, superficial muscle, muscle tendon, superficial ligament, subcutaneous bursa, periosteum b. Dull, Aching - bone, subchondral bone, tendon sheath, deep muscle, deep ligament, bursa, fibrous capsule, joint c. Tingling - peripheral nerve (common peroneal nerve), nerve root problem, circulation problem d. Twinges with Movement - superficial ligaments or muscles e. Stiffness - usually muscular or capsular in origin, chondromalacia, joint effusion, rheumatoid arthritis, osteochondritis, osteoarthritis 4. Severity of Pain - not a good indicator of seriousness of injury 5. Timing of Pain a. What makes it better? rest, heat or cold, elevation of limb - acute injuries feel better when rested & iced, chronic injuries feel better when moved & heated, elevation decreasing pain indicates active inflammation b. What makes it worse? Walking, squatting, climbing stairs, jumping - descending stairs is usually more painful in patellofemoral problems, squatting aggravates chondromalacia & meniscal tears, walking & weight-bearing activities aggravate degenerative joint disease, jumping aggravates patellofemoral problems c. Pain on Movement - acute muscle strains & tendonitis become worse with movement, ligaments are painful when stretched, periosteal pain or bone injuries are aggravated by vibration, synovial plica problems & iliotibial band syndrome are aggravated by repeated flexion & extension d. Morning Pain - typical of degenerative joint disease C. Swelling 1. Location a. Local - usually local bursa & extra-articular injuries b. Diffuse 2. Time of Swelling a. Immediate-Within 30 Minutes to 2 Hours - usually indicates a hemarthrosis, joint becomes tense, most commonly is ACL tear, patellar subluxation, chondral or osteochondral fx, peripheral tear of meniscus, PCL tear b. After 6 to 24 Hours - usually synovial in origin indicating meniscal tear, osteochondritis dissecans, capsular sprain, patellar subluxation 3. Amount of Swelling - does not clearly indicate severity of injury, tense effusion indicates intra-articular injury without significant capsular injury, some sever injuries may not appear to swell much 4. When the Knee Swells - rotational activities aggravate ligamentous & meniscal problems, jumping aggravates patellofemoral problems, kneeling aggravates chondromalacia, prepatellar & infrapatellar bursa, swelling at end of day suggests weight-bearing is aggravating joint D. Function 1. Degree of Disability 2 a. Return to Play - not always clear indicator of severity, but generally if significantly unstable continued activity will cause further episodes of instability b. Weight Bearing - feelings of insecurity & unwillingness to weight-bear suggests severe injury, instability with cutting & changing directions suggest ligamentous instability 2. Range of Motion - immediate loss of passive ROM suggest acute muscle spasm, internal derangement such as meniscal tears, loss of ROM later suggest gradual hemorrhage or muscle spasm 3. Weakness - may be from muscle guarding or neural trauma, reflex inhibition of local muscles 4. Locking a. Meniscal Tear b. Loose Body c. Isolated Tear of Anterior Cruciate Ligament d. Peripheral Hemorrhage e. Posterior Hemorrhage - can block full extension & simulate locking 5. Daily Function - posterolateral instability unable to fully extend knee & trouble ascending & descending stairs, anterolateral instability causes episodes of giving way especially with decelerating or twisting, meniscal tears cause slipping or shifting E. Instability 1. Medial Instability - tibial collateral, ACL, medial meniscus 2. Lateral Instability - iliotibial band, lateral capsule, arcuate ligament, fibula collateral 3. Giving Away - meniscus tear, cruciate tear, chondromalacia, patellar subluxation, osteochondritis dissecans, weak quadriceps F. Sensations 1. Clicking - meniscus tears, patella 2. Snapping - synovial plica, discoid lateral meniscus, osteochondral fx 3. Grating - chondromalacia, osteochondritis, osteoarthritis 4. Tearing - muscle or ligament 5. Catching - meniscal tear, patellar subluxations 6. Tingling - neural or circulatory problem 7. Hypesthesia/Hyperesthesia - local nerve or nerve root problem 8. Warmth - local inflammation, infection, gout 9. Popping - ACL tear, subluxed patella, meniscal tear, muscle tear such as hamstring tear G. Particulars - previous history, diagnosis, recommendations II. Observations A. Standing 1. Anterior View a. Alignment (1) Pelvis - if unlevel, could be leg-length discrepancy, shorter leg has more injuries (2) Anterior Superior Iliac Spine (3) Femoral Anteversion - associated with patellar malalignment syndromes, patellar subluxations, chondromalacia (4) Femoral Retroversion - can cause some patellar malalignment problems (5) Genu Varum(Coxa Valgum) - puts extra load through fibula collateral ligament, causes crossover running style leading to overuse problems (6) Genu Valgum(Coxa Varum) - (more common in women) can cause calcaneal valgus, resulting pronation, patellar malalignment, internal tibial rotation, increased Q angle b. Patella (1) Q-angle - leads to patellofemoral malalignment conditions (chondromalacia, patellar tendonitis, patellar retinaculum problems, retropatellar irritation), patella subluxation/dislocation (2) Squinting Patellae - suggestive of femoral anteversion, usually accompanied by genu valgum (3) Fisheye Patella - outward facing patella, usually caused by femoral retroversion, more susceptible to subluxation or dislocation (4) Patella Alta - associated with malalignment problems, chondromalacia, patellar instability (5) Patellar Size - often unstable, more susceptible to subluxation/dislocation c. Tibial Torsion -internal or external tibial torsion can affect patella tendon alignment, increasing susceptibility to malalignment syndromes, chondromalacia, patellar tendinitis d. Tibial Varum - causes compensatory calcaneal eversion & resulting pronation e. Pronated Foot or Feet - causes excessive internal tibial rotation stressing patellofemoral joint, patellar tendon, lateral joint structures, & medial meniscus f. Muscle Wasting (1) Quadriceps (especially VMO) can be caused by pain inhibition, restriction of joint movement, leads to malalignment conditions g. Swelling (1) Suprapatellar Bursa - may be intra-articular or extra-articular, intra-articular lifts patella off femoral condyles (2) Infrapatellar Bursa - between patellar tendon & proximal tibial (3) Prepatellar Bursa - lump between anterior patella & skin 3 (4) Pes Anserine Bursa - local swelling under tendinous insertion of gracilis, semitendinosus, & sartorius B. Posterior View 1. Alignment a. Lumbar Spinous Processes - check for scoliosis, leg -length difference, prominent L5 spinous process may indicate spondylolisthesis b. Paraspinal Muscle Spasm - can indicate facet joint dysfunction or disc herniation which may refer pain to leg c. Iliac Crests - if unlevel, could be leg-length discrepancy, shorter leg has more injuries d. Posterior Superior Iliac Spine e. Popliteal Crease - if unlevel could be functional or structural leg-length discrepancy f. Calcaneal Inversion g. Calcaneal Eversion - causes excessive pronation keeping tibia internally rotated too long causing patella malalignment problems 2. Muscle Wasting (Atrophy) atrophy of buttocks & hamstrings can occur from hip arthritis, hamstring atrophy from previous hamstring injury, knee injury, muscle imbalance 3. Muscle Hypertrophy -hamstring hypertrophy in sprinting, gastrocnemius hypertrophy in jumping 4. Swelling a. Baker's cyst - synovial effusion in gastrocnemius or semimembranosus bursa caused by lesion in posterior segment of medial meniscus, most common cause of popliteal cyst in middle age, can be caused by defect or degeneration in posterior joint capsule C. Lateral View 1. Alignment a. Excessive Lumbar Lordosis b. Anterior Pelvic Tilt - tight low back muscles or hip flexors, weak & stretched abdominals, hamstrings, glutei c. Genu Recurvatum - associated with hypermobile patella & generalized ligament laxity d. Flexed Knee - can be caused by acute spinal derangement, knee joint effusion, acute tibial collateral sprain, meniscal tear, quadriceps insufficiency or reflex inhibition, acute chondromalacia 2. Lesion Site a. Bruising, Tracking, Ecchymosis b. Scars c. Skin Color d. Deformity 3. Gait a. Stride Length b. Step Length c. Degree of Toe Out - angle of foot placement is normally 70 from sagittal plane, angle of toe out > 70 can cause excessive pronation problems, longitudinal arch collapse, decreased stride length, rotational torsion through entire lower limb d. Stride Width - usually 2 to 4 ", usually widened if heavy thighs, balance problems, or decreased sensation in heel or sole of foot e. Rhythm - antalgic gait occurs when time spent weight-bearing on injured limb is shortened 4. Walking Cycle a. Heel Strike - when unable to fully extend knee, patient will put entire foot down carefully b. Foot Flat and Midstance - knee needs to reach full extension in this phase, any problem limiting full extension will affect this part of gait. During midstance, tibia externally rotates while foot supinates & midtarsal joint locks so foot can become rigid for strong push-off. c. Push-off and Acceleration - A weak push-off is evident in most knee joint injuries d. Midswing and Deceleration - fewer symptoms during this part of gait 5. Alignment a. Anterior View (1) Pelvic control - weakness in gluteals or quadratus lumborum can cause pelvic dropping on one side (2) Patellar Tracking - if patella deviates, patellar malalignment problems may exist b. Posterior View (1) Knee Range - look for full knee extension during heel strike & midstance (2) Achilles Alignment (3) Prolonged Pronation (4) No Pronation 6. Muscle Wasting a. Anterior View (1) Quadriceps - look for atrophy when quadriceps contracts b. Posterior View (1) Gastrocnemius, hamstrings D. Sitting 1. Long Sitting - slight knee flexion in long sitting suggest joint effusion or hamstring spasm, look for atrophy, swelling, patella posture 4 2. High Sitting - assess patella position, lateral position indicates vastus medialis weakness, vastus lateralis tightness, or underdeveloped lateral femoral condyle. Assess for patella alta. III. Palpation (both supine & prone) A. Palpate for effusion in knee joint (milking down suprapatellar pouch , feeling for fluid wave) 1. Brush, Stroke, or Bulge Test (Wipe Test) - assesses minimal effusion, slight-to-moderate intracapsular swelling. Begin medial to patella below joint line & stroke upward around patella & over suprapatellar pouch to move swelling proximally. The opposite hand strokes down on the lateral side of the patella, look on medial side of joint for fluid movement. A fluid wave passes to medial side & bulges just below medial distal portion or border of patella. Fluid wave may take a couple of seconds to appear. 2. Indentation Test - Pt. lies supine while examiner observes indentation at lateral side of patellar tendon when normal knee is flexed. Involved knee is flexed while indentation is compared to normal knee. Stop flexion of involved knee when indentation disappears and compare this range of flexion with that of normal knee. The greater the swelling, the sooner in the range the indentation disappears. Use the your thumb and finger on each side of patellar tendon to fluctuate back & forth. 3. Peripatellar Swelling Test - Pt. is supine with knee extended. Examiner carefully milks fluid from suprapatellar pouch distally with one hand while other hand palpates on each side of patella tendon for fluid accumulation. 4. Fluctuation Test - Examiner places palm over suprapatellar pouch with other palm over anterior joint with thumb & index finger just beyond patella margins. Press with one hand, then the other to feel slight-to-moderate swelling. Blood fluctuates in a block (like jelly moving) whereas clear effusion runs down smoothly. Synovial fluid can be felt to fluctuate under the hands & move from one hand to other, indicating significant effusion. 5. Patellar Tap Test (Ballotable Patella) (Dancing Patella Sign) - Extend or flex pt.'s knee to discomfort (which increases effusion pressure in joint) and apply a slight tap or pressure over patella. If significant effusion is present the patella will appear to float or dance. A floating sensation of the patella over fluid is felt or a tap occurs as the patella goes through swelling before hitting condyles. B. Bony Palpation 1. Femur a. medial/lateral femoral condyles b. epicondyles c. adductor tubercle d. trochlea groove 2. Patella a. inferior & superior poles b. medial & lateral facets 3. Tibia a. medial/lateral tibial plateaus b. tibial tubercle c. Gerdy's tubercle 4. Fibula a. head b. neck C. Anterior Soft Tissue Palpation 1. Vastus Medialis 2. Vastus Medialis Oblique 3. Rectus Femoris 4. Patellar tendon 5. Bursae(Superficial Infrapatellar, Prepatellar, & Pes Anserine) D. Medial Soft Tissue Palpation 1. Medial Meniscus 2. Tibial Collateral Ligament 3. Pes Anserine(Sartorius, Gracilis, Semitendinosus) 4. Semimembranosus 5. Suprapatellar plica E. Lateral Soft Tissue Palpation (Figure 4 position) 1. Lateral Meniscus 2. Fibula Collateral Ligament 3. Biceps femoris tendon 4. Iliotibial tract F. Posterior Soft Tissue Palpation 1. Gastrocnemius(medial & lateral heads) 2. Popliteal Fossa G. Skin temperature and texture H. Pulses: Popliteal pulse I. Reflexes: Patellar reflex (L4) IV. Functional Testing 5 A. Rule Out 1. Inflammatory disorders - arthritis, gout, & osteoarthritis 2. Lumbar Spine 3. Hip Joint 4. Superior tibiofibular joint - can cause lateral leg & knee pain 5. Foot and ankle - can refer pain into knee particularly if tibia is involved 6. Fracture a. Femur b. Patella c. Tibia d. Fibula B. Functional Tests 1. Active knee flexion (1350) - Pain, weakness, or limitation of ROM can be caused by muscles or their nerve supply a. Semimembranosus - sciatic N. (tibial branch, L4, L5, S1) b. Semitendinosus - sciatic N. (tibial branch, L4, L5, S1) c. Biceps femoris - sciatic N. (tibial branch, L5, S1, S2) Patellar crepitus may be caused by chondromalacia. Patella clicking may be caused by synovial plica. Lateral clicking may be iliotibial band over the lateral epicondyle. Full flexion may be limited by joint effusion. 2. Passive knee flexion (1350) - Pain and/or limitation of ROM can come from: a. anterior capsule with intracapsular joint swelling b. quadriceps muscle due to muscle strain, tear, or hematoma c. posterior capsule with intracapsular swelling or a Baker's cyst d. patellar tendonitis e. patellar tendon strain or tear f. infrapatellar bursitis g. prepatellar bursitis h. suprapatellar bursitis i. medial or lateral collateral sprain j. patellar fracture 3. Active knee extension (00 to 150) Pain, weakness, or limitation of ROM can be caused by muscles or their nerve supply a. quadriceps - rectus femoris, vastus medialis, vastus intermedius, vastus lateralis - femoral N. (L2, L3, L4) b. Three abnormal patellar tracking problems (1) bayonet movement - causes an abrupt lateral translation of the patellar before full extension, then further extension in a straight line (2) an abrupt lateral translation at end of knee extension (3) a semicircular route as if the patella is pivoting around the lateral patella facet Abnormalities in patellar tracking can be caused by (a) bony abnormalities of patella or patellar sulcus (b) support structure abnormalities (retinaculum, plicas) (c) muscle imbalances in the quadriceps (d) asynchronous muscle firing of the quadriceps Patellar crepitus & pain beginning beyond 300 of flexion can indicate chondromalacia. Jerky patellar tracking during extension can be caused by weak VMO or subluxing patella tendency Snapping near full extension or between 400 t0 600 of flexion suggests suprapatellar plica problem. Stuttering of the patella may occur for same reason. Limitation of full extension can be caused by: (i) meniscal displacement (ii) intra-articular loose body (iii) joint effusion (iv) ACL tear (v) acute tibial collateral ligament sprain 4. Passive knee extension (00 to 150) - end feel should be tissue stretch. Pain or limitation of ROM can be caused by: a. tibial collateral ligament sprain b. hamstring strain or tear c. medial or lateral collateral ligament sprain d. Pain on anterior joint line at end of passive extension suggests a fat pad lesion. e. Pain in popliteal fossa indicates a popliteal muscle strain or tear or Baker's cyst. f. Increased extension or hyperextension with pain suggests a posterior capsule tear. 5. Active internal (300) & external rotation (400) of the tibia on the femur a. Internal rotation - Pain, weakness, or limitation of ROM can be caused by muscles or their nerve supply: (1) Semimembranosus - sciatic N (tibial branch L4, L5, S1) (2) Semitendinosus - sciatic N (tibial branch L4, L5, S1) (3) Popliteus - tibial N. (L5, S1, S2) 6 b. External rotation - Pain, weakness, or limitation of ROM can be caused by muscles or their nerve supply - Biceps femoris - sciatic N. (tibial branch L5, S1, S2) c. Pain or limitation of ROM can be caused by meniscal tears, joint effusion, or tibiofemoral joint injury 6. Passive internal & external rotation of the tibia on the femur - internal rotation increases tension on posterolateral structures, external rotation increases tension on anteromedial & posteromedial structures a. Pain and/or limitation of ROM with passive internal rotation can come from: (1) posterolateral capsular sprain (2) arcuate ligament sprain (3) popliteal tendon, strain, tear, or tendinitis (4) iliotibial band strain or tear (5) fibular collateral ligament sprain b. Pain and/or limitation of ROM with passive external rotation can come from: (1) posteromedial capsular sprain (2) tibial collateral ligament sprain (3) coronary ligament sprain (4) pes anserine bursitis (5) semitendinosus strain or tear (6) semimembranosus strain or tear (7) gracilis strain or tear 7. Resisted internal & external rotation of the tibia on the femur - pain and/or weakness can be caused by injury to the muscles or their nerve supply a. pes anserinus bursitis b. semitendinosus or semimembranosus strain 8. Resisted knee extension (midrange) - pain and/or weakness can be caused by injury to the muscles or their nerve supply, patellofemoral problems 9. Resisted knee flexion (midrange) - pain and/or weakness can be caused by injury to the muscles or their nerve supply a. Test medial hamstrings by resisting flexion with knee in internal rotation b. Test lateral hamstrings by resisting flexion with knee in external rotation C. Special Tests - Tibiofemoral joint 1. Iliotibial Band Friction Syndrome Tests a. Noble test - lying with knee in flexion up to 900 while examiner stands to involved side & places thumb over the lateral epicondyle of the involved knee. The examiner's other hand is used around the pt.'s ankle to passively flex & extend the knee. With the pressure maintained by the thumb, the pt. is questioned as to whether pain occurs under the thumb when the knee is in 300 of flexion which indicates the presence of iliotibial band friction syndrome. b. Renne - Examiner sits or squats in front and to the side and places their thumb over the lateral epicondyle and maintains pressure while the subject performs a squat. If pain is present under the examiner's thumb at 300 of flexion (when the iliotibial band lies directly over the lateral epicondyle), it indicates iliotibial band friction syndrome is present. 2. Apley's distraction test - knee flexed 900, stabilize femur with one knee over back of leg, lift up on tibia & foot to distract joint line, rotate medially & laterally to see if painful indicating collateral ligament damage 3. Valgus Stress Test (Abduction Stress) (medial collateral ligament) a. In full extension - (straight medial instability) injury to tibial collateral ligament & PCL b. In 300 flexion - (anteromedial rotary instability) injury to tibial collateral, posteromedial capsular sprain, posterior oblique ligament, ACL 4. Varus Stress Test (Adduction Stress) a. In full extension - (straight lateral instability) injury to lateral capsular & fibula collateral ligament, & PCL, biceps tendon, arcuate complex b. In 300 flexion - rotary (anterolateral instability) injury to lateral capsular, fibula collateral ligament, iliotibial band, posterior oblique ligament, arcuate-popliteus complex, ACL 5. Drawer sign or test a. Anterior - ACL (anterolateral, anteromedial, or straight anterior instability) (1) Passive (2) Modified anterior drawer test for rotary instability (a) Anteromedial rotary instability (Slocum and Larson's test) - positioned in external rotation, anterior displacement of medial tibia indicates anteromedial rotary instability caused by tibial collateral, posterior oblique, ACL, medial capsular sprain (b) Anterolateral rotary instability - positioned in internal rotation, anterior displacement of lateral tibia indicates anterolateral rotary instability caused by lateral capsular, arcuate complex, ACL, fibula collateral sprain (c) Posterolateral rotary instability - positioned in external rotation, posterior displacement of lateral tibia indicates posterolateral rotary instability caused by arcuate complex, lateral capsular sprain, biceps femoris, ACL (3) Active b. Posterior - PCL (straight posterior instability) (1) Passive 7 (a) Reverse Lachman - same as prone Lachman except tibia is pushed posteriorly instead of anteriorly to determine posterior cruciate laxity. (b) Godfrey 90/90 - Pt. lies relaxed while examiner places hips & knees in 900 of flexion. Examiner observes from the side compares tibial step off from femur with lateral view. (c) Posterior sag sign (gravity drawer) (posterior cruciate) supine, both hips are flexed 450 & both knees 900. Observe & compares tibial step off from femur with lateral view. (2) Active (a) Quadriceps active test - supine with knee flexed 900 in drawer test position, fire quad to elicit active anterior drawer to reduce passive posterior drawer, reverse procedure with active hamstring contraction to reduce tibial step off & increase posterior drawer 6. Lachman test (anterior cruciate ligament) -establish absence of firm end point & assess anterior translation a. traditional b. thigh support c. table side d. drop leg e. prone f. active 7. Dejour test - pt. lies supine while examiner holds pt.'s leg with in against examiner's body with one arm and the hand under the calf to lift tibia while applying a valgus stress. Other hand pushes the femur down. In extension, this causes anteromedial subluxation in the unstable knee. If the knee has anteromedial instability & is then flexed, the tibial plateau reduces suddenly, indicating a + test. If the reduction is painful, it indicates medial meniscal injury. If not painful, it indicates posteromedial corner has been injured. 8. Pivot shift tests for anterolateral instability a. Jerk test (Hughston) supine, hip flexed 450, knee flexed 900, apply valgus force behind fibula & extend slowly, observe for jerk movement at 300 b. Method 2 - same as above except position leg under axilla & repeat movements with forces c. MacIntosh test - supine relaxed, passively lift heel to 200 of hip flexion, apply internal rotation to lower leg while lifting back of lower leg, allow knee to flex 20 to 50, then apply medial push with proximal hand & lateral push with distal hand. As internal rotation, valgus force, & forward displacement are maintained, knee is slowly passively flexed, watch for sudden, visible, audible, & palpable reduction at 200 to 400 of flexion. d. Losee test - supine, relaxed with ankle between arm & chest, maintain tibia externally rotated, apply valgus & superior axial force with knee extended, slowly flex knee allowing medial tibial rotation. At 150 to 200 of flexion lateral tibial plateau becomes visible and clunk may be felt. e. Slocum's ALRI test - sidelying with affected side up, roll pelvis posteriorly 300 from supine with medial foot resting on table with knee flexed 100. Palpate posterolateral joint, tibial & femoral condyles for tibia subluxed anteriorly & internally rotated (for anterolateral rotary instability) on femur. Apply valgus force while flexing knee, positive instability is felt as knee reduces at flexion angle of 250 to 450. Variation is done with tibia externally rotated fee anteromedial rotary instability. f. Bach et al. Test - supine with hip abducted 300, knee extended, tibia externally rotated 200. Place one hand on medial malleolus & tibia, holding leg in abduction & tibia in external rotation. Place other had on lateral knee joint. Apply constant axial compressive force while flexing knee. g. Crossover Test of Arnold - The standing pt. is asked to cross the uninvolved leg in front of the involved leg. Examiner uses their foot to stabilize pt.'s involved foot. Pt. is instructed to rotate upper torso away from the involved leg approximately 900 from fixed foot. When in position, pt. contracts quadriceps, producing same symptoms by stressing same structures as in lateral pivot shift. h. Noyes Flexion-Rotation Drawer Test - Pt. supine while examiner holds pt.'s ankle between examiner's trunk & arm with hands around tibia. Examiner flexes pt.'s knee to 200 to 300 while maintaining tibia in neutral rotation. Tibia is then pushed posteriorly like a posterior drawer to reduce the tibial subluxation, which indicates a + test for ALRI. If tibia is alternately pushed posteriorly & released and the femur is allowed to rotate freely, the reduction & subluxation are seen & felt as femur rotates medially & laterally. i. Lemaire's Jolt Test - Position pt. in sidelying with involved leg up. Pt. must relax. Examiner uses one hand to hold foot & internally rotate tibia with knee in extension. Examiner uses back of other hand to lightly push against biceps tendon & fibular head while the hand on the foot flexes & extends the knee. If at 150 to 200 of flexion a "jolt" occurs with tibial displacement it is a + sign for ALRI. j. Flexion-Extension Valgus Test - Pt. lies supine while examiner holds pt.'s ankle between examiner's trunk & arm with hands around tibia. Examiner palpates joint line with thumb & fingers of both hands, and a valgus stress & axial compression are applied while knee is flexed & extended. IF ACL is torn, examiner feels the reduction & subluxation. k. Nakajima Test - Pt. lies supine, & examiner stands on side of the involved leg and holds pt.'s foot with one hand to internally rotate tibia with knee flexed 900. Other hand is placed over lateral femoral condyle with thumb behind fibular head to push it forward. Examiner then slowly extends knee while pushing fibular head forward. If subluxation is felt it is + for ALRI. 8 l. Martens Test - Pt. supine while examiner holds pt.'s ankle between examiner's trunk & arm with hands around tibia. Examiner holds pt.'s leg just distal to knee joint with one hand & pushes femur posteriorly with other hand. Valgus stress is applied while knee is flexed until tibia reduces which indicates + test for ALRI. m. Active Pivot Shift Test - Pt. sits in chair with foot secure on floor and knee flexed 900 in neutral rotation. Pt. contracts quadriceps isometrically while examiner holds foot. If lateral tibial plateau subluxes anteriorly it indicates anterolateral instability. 9. Posteromedial Rotary Instability Tests a. Hughston's Posteromedial & Posterolateral Drawer Test - Pt. lies supine with knee flexed 800 to 900 & hip flexed 450 Examiner medially rotates pt.'s foot slightly and sits on it with their hip to stabilize it. Examiner then pushes tibia posteriorly. If tibia moves or rotates posteriorly excessively in comparison to normal, posteromedial rotary instability is indicated. b. Posteromedial Pivot Shift Test - Pt. lies supine and examiner passively flexes knee more than 450 while applying a varus stress, compression, & internal rotation to cause posterior subluxation of medial tibial plateau. Examiner then takes knee into extension. If knee shifts into reduced position at 200 to 400 of flexion it indicates + test indicating tibial collateral ligament, posterior oblique ligament, & posterior cruciate ligament. 10. Posterolateral Rotary Instability Tests a. Hughston's Posterolateral Drawer Test - Pt. lies supine with knee flexed 800 to 900 & hip flexed 450 Examiner laterally rotates pt.'s foot slightly and sits on it with their hip to stabilize it. Examiner then pushes tibia posteriorly. If tibia moves or rotates posteriorly excessively in comparison to normal, posterolateral rotary instability is indicated b. Reverse Pivot Shift (Jakob Test) Supine method - Examiner uses proximal hand on pt.'s posterolateral leg just distal to the patella, with the thumb on or anterior to the fibular head. The distal hand is used around the pt.'s midfoot and heel to externally rotate the tibia while the proximal hand applies valgus stress during slow passive extension of the knee from the original position of 450 of flexion. The shift is first seen during flexion when the lateral tibial plateau subluxes posteriorly. This subluxation is reduced once the knee extends to around 200 of flexion. At 200 the lateral tibial plateau returns to neutral and a palpable clunk or shift may be felt if posterolateral rotary instability is present which occurs secondary to fibula collateral, posterolateral capsule, and arcuate complex. c. Reverse Pivot Shift (Jakob Test) Standing method - Pt. stands and leans against wall with uninjured side adjacent to the wall & body weight distributed equally. Examiner's hands are placed above & below involved knee, and a valgus stress is applied while flexion of pt.'s knee is initiated. If knee jerks or tibia shifts posteriorly and giving way phenomenon occurs it indicates posterolateral rotary instability possibly involving posterior cruciate ligament, arcuate-popliteus complex, fibula collateral ligament, biceps femoris tendon, posterolateral capsule, anterior cruciate ligament d. External Rotation Recurvatum Test - posterolateral instability - hold feet by heels with knees extended, quadriceps relaxed. Observe tibial displacement posteriorly in relation to lateral femoral condyle. e. Loomer's Posterolateral Rotary Instability Test - Pt. lies supine & flexes both hips & both knees to 900. Examiner then holds the feet & maximally externally rotates both tibias. Observe to see if involved tibia rotates excessively in comparison to normal knee. Also observe to see if involved tibial tuberosity sags posteriorly. Both signs must be present for a + test. Similar to the Bousquet external hypermobility test. Also known as the Dial test. f. Dynamic Posterior Shift Test - Pt. is supine while examiner flexes involved knee & hip to 900 flexion with femur in neutral rotation. One hand stabilizes the anterior thigh while the other hand extends the knee. If tibia reduces with a clunk as extension is obtained, it is + for posterior & posterolateral instability. If painful before extension, hip flexion may be decreased but hamstrings must be kept tight. g. Active Posterolateral Drawer Sign - Pt. sits with foot on in neutral & flexed 800 to 900. Pt. is asked to isometrically contract the biceps femoris while examiner stabilizes the foot. If lateral tibial plateau subluxes posteriorly it is + for PLRI. 11. Menisci Tests a. McMurray's meniscus test - palpate joint lines while taking knee into full flexion & extension with it internally rotated & externally rotated (1) flexion & external rotation with valgus force- draws medial meniscus anteriorly & lateral meniscus posteriorly (2) flexion & internal rotation with varus force - draws lateral meniscus anteriorly & medial meniscus posteriorly (3) extension & internal rotation with varus force - compresses lateral meniscus (4) extension & external rotation with valgus force - compresses medial meniscus b. Medial & Lateral Compression (Grind) tests specific portions of above McMurray test to target specific aspects of the menisci. c. Apley's compression test - knee flexed 900, lean on heel to compress joint surfaces together, rotate medially & laterally while using other hand to palpate joint lines for popping, clicking, or catching indicating possible meniscal tears d. Bounce Home Test - Pt. is supine while examiner cups heel of involved extremity and flexes knee and allows passive extension. Lack of full extension suggests torn meniscus, loose body, or significant intracapsular swelling. If knee does not fully extend or has a rubbery or springy end feel such as a springy block, it indicates mechanical blocking of full extension, which is most likely a torn meniscus. Springy block as the end feel suggests a torn meniscus caught between bone ends (displaced bucket handle tear) 9 e. O'Donohue's Test - Pt. is supine while examiner flexes knee to 900, rotates it internally & externally twice, then fully flexes & rotates it both ways again. Test is + for meniscal tear or capsular irritation if pain is increased on rotation in either or both positions. f. Modified Helfet Test - Normally, the tibial tuberosity is in line with midline of patella when knee is flexed 900. When knee is extended, tibial tubercle should be in line with lateral border of patella. If this change does not occur, it means rotation is blocked, indicating meniscal injury, or possible cruciate injury. g. Test for Retreating or Retracting Meniscus - Pt. sits on edge of examining or lies supine with knee flexed 900. Examiner places one finger over the joint line of pt.'s knee anterior to tibial collateral ligament, where curved margin of medial femoral condyle approaches the tibial tuberosity. The leg & foot are then passively externally rotated, and the meniscus normally disappears. The leg is internally & externally rotated several times, with the meniscus appearing & disappearing. If meniscus does not appear, it indicates a torn meniscus because rotation of tibia is not occurring. h. Steidman's Tenderness Displacement Test - Point tenderness & pain on the joint line that appears to move anteriorly when knee is extended & moves posteriorly when knee is flexed indicates a possible meniscus tear. Medial pain is elicited on external rotation & lateral pain on internal rotation. i. Payr's Test - Pt. lies supine in Figure 4 position to see if painful is elicited in medial joint line which indicates a medial meniscus lesion in the mid or posterior portion. j. Bohler's Sign - Pt. lies supine while examiner applies varus & valgus stress to knee. Pain on lateral side with valgus stress indicates lateral meniscal pathology. Pain on medial side with varus stress indicates medial meniscus pathology. k. Bragard's Sign - Pt. is supine while examiner flexes pt.'s knee. Examiner then externally rotates tibia & extends knee. Pain & tenderness on medial joint line indicates medial meniscus pathology. If examiner then medially rotates knee tibia & flexes knee, pain & tenderness will decrease. l. Kromer's Sign - Similar to Bohler's sign except knee is flexed & extended while varus & valgus stress is applied. Pain on lateral side with valgus stress indicates lateral meniscal pathology. Pain on medial side with varus stress indicates medial meniscus pathology. m. Childress Sign - Pt. squats & performs a "duck walk". Pain, snapping, or a click is considered + for posterior horn lesion of meniscus. n. Anderson Medial-Lateral Grind Test - Pt. is supine while examiner holds leg between trunk & arm while index finger & thumb of opposite hand are placed over anterior joint line. Valgus stress is applied to knee as it is passively flexed to 450, then a varus stress is applied to knee as it is passively extended, producing a circular motion to knee. Motion is repeated, increasing varus & valgus stress with each rotation. Distinct grinding felt in...