Special Tests of Knee

Patellar Glide test

Knee flexed 20-30, quadriceps relaxed
Patella divided into quadrants and displaced in medial and lateral directions to assess tightness of parapatellar structures
Medial glide of 1 quadrant = tight lateral structures

ref: Kolowich etal " Lateral release of the patella: indications and contraindications" Am J Sports Med 18: 359, 1990

Patellar Tilt test

Knee extended, quadriceps relaxed
Examiner lifts lateral edge of patella from the lateral femoral condyle
Tight lateral structures indicated in neutral or negative angle to the horizontal

ref: Kolowich etal Am J Sports Med 18: 359, 1990

A-P drawer

First inspect to determine if there is any posterior sagging (may get false positive anterior drawer in a knee that is really PCL deficient)
Knee at 90, do anterior drawer in neutral as well as 30 IR and 15 ER
In ER, medial complex should become tight; abnormal laxity = injury to posteromedial corner
In IR, lateral complex should tighten and in the normal knee reduce anterior drawer; abnormal laxity = injury to posterolateral corner
The IR/ER part is called the Slocum test

ref: Marshall etal "The Anterior Drawer Sign – What is it? J Sports Med 3: 152, 1975

Lachman test

Perform an anterior drawer test at 15 degrees of flexion
The most sensitive test for ACL deficiency

Flexion Rotation Drawer Test

Anterior force is applied to the tibia in 15 of flexion, resulting in anterior subluxation as in the Lachman test
With further knee flexion the tibia reduces beneath the femur with a clunk and internal rotation of the femur

Pivot Shift

3 requisites: non functioning ACL, an intact medial complex and an intact iliotibial tract
Foot held in internal rotation with one hand and the leg slightly abducted, the other hand is placed on the lateral side of the leg at the level of the fibular head
Apply a valgus thrust to the leg and gently flex it
If positive, subluxation will reduce at 20-30 with the lateral femoral condyle sliding forward on the tibial plateau to a reduced position

ref: Galway, Beupre, Mackintosh JBJS 54B: 763-764, 1972

Jerk Test

Start with the knee flexed and apply a valgus and IR force to sublux the lateral tibial condyle anteriorly
As the knee is extended the tibia reduces with a clunk

Quadriceps Active Test

Patient supine, knee flexed to 90, foot flat on the table
In the PCL deficient knee, tibia assumes a resting position posterior to normal
Quadriceps contraction against resistance produces anterior tibial translation

ref: Daniel etal JBJS 70A:386, 1988 "Use of the Quadriceps Active test to diagnose PCL disruption and measure posterior laxity of the knee"

Dynamic Posterior Shift Test

Leg positioned with the hip at 90 flexion and knee is slowly extended from 90 of flexion; Tibia is in a posteriorly subluxed position
In PCL insufficiency, as the knee extends, suddenly reduces with a clunk

ref: Shelbourne etal Am J Sports Med 17:275, 1989

Posteromedial Pivot Shift

Elicited by flexing the knee more than 45 degrees, while applying a varus stress, compression and IR
As the knee is brought into extension, the tibia suddenly reduces, ~ 20-40 degrees short of full extension
To be positive, PCL, MCL and posterior oblique ligament should be divided

ref: Owens JBJS 76A:532-539, 1994

External Rotation Recurvatum Test

Patient being supine, lift the legs by the great toe
Positive, when knee falls into varus hyperextension and tibial ER
Hughston stated this test to be specific for injury to the arcuate complex (LCL, arcuate ligament, popliteus, lateral gastrocnemius)
Insall believes that the test will be mildly positive with isolated injury to the posterolateral corner, but for excessive hyperextension and varus to be present, ACL must be torn and possibly the PCL too

ref: Hughston and Norwood- CORR 147:82, 1980

Posterolateral Drawer Test

Perform posterior drawer test, with knee at 90 flexion and foot 15 ER
If positive, lateral tibial plateau moves posteriorly on the femoral condyle; in contrast, the medial condyle does not move
When asymmetrical = pathological ER of tibia
When the posterolateral structures are sectioned, ER of tibia increases ~5 at 90 of flexion
When the PCL is torn, ER at 90 flexion increases another 15 ,if this test grossly positive, PCL is probably damaged

ref: Hughston and Norwood- CORR 147:82, 1980

Reverse Pivot Shift Test

Elicited by bringing the knee from a position of 90 flexion, where it is subluxed, to the fully extended position under a valgus load and foot externally rotated, where it reduces
Jakob test is grossly positive in 3% and weakly positive in 8% of normal knees
This has been found to correlate with ligamentous laxity
When the test is asymmetrical comparing to other side or reproduces symptoms, indicates posterolateral instability

ref: Jakob, Acta Orthop Scand (supp) 52: 1, 1981

External Tibial Rotation

Prone, knees at 30 and at 90, foot is forcefully rotated externally
The degree of rotation of the medial border of the foot is measured relative to the femur and compared with the contralateral side
Palpate the tibial plateau to determine its relative position to the femoral condyles; this is to confirm that the increased ER is due to posterolateral instability rather than anteromedial instability
There is considerable inter-individual variation in degree of maximal ER at 30 flexion: average 30, range 15-45 .At 90 flexion: average 37, range 15-70

Meniscal Tests

Numerous rotation tests for meniscal pathology have been described
All have the common purpose of trapping abnormally mobile or torn fragments of menisci between the joint surfaces, causing pain or clicking

McMurray Test

Intended to diagnose lesions of the posterior horn of the meniscus
Patient supine, hip flexed 90 and knee flexed more than 90
For examining the right knee, the examiner stands to the patient’s right side with left hand on the knee and right hand holding the foot
The foot is taken from a position of abduction and ER to one of adduction and IR
This is repeated for various angles between full flexion and 90 ,trapping of damaged meniscus is felt as a clunk by the fingers on the joint line

ref: McMurray, TP: "The Semilunar Cartilages" Br J Surg 29: 407, 1941

Steinmann Test

Patient seated, with knee hanging loose over the edge of the table, knee flexed at least 90,grasp the foot and rotate tibia sharply into IR then ER
Meniscal lesion is demonstrated by pain at the appropriate joint line

ref: Ricklin etal, " Meniscal lesions: Problems of clinical diagnosis , arthrography and therapy", Grune and Stratton, Orlando, FL, 1971

Apley Test

Patient prone ,knee flexed > 90, downward pressure is applied to the foot and joint surface thereby rotated and compressed slightly
The maneuvre is repeated this time with distraction rather than compression
Meniscal lesions will be demonstrated by clicking or pain in the compression part of the test, while ligamentous injuries cause pain when the joint is distracted

ref: Apley AG: " The diagnosis of meniscus injuries: some new clinical methods" JBJS 29B:78, 1947