Examination of the Knee
Ed Mulligan, PT, DPT, OCS, SCS, ATCClinical Orthopedic Rehabilitation Education
Examination of the Knee
subjective evaluation of the kneehelp set the pre-exam probabilities of the diagnosis
HISTORY:• Age and Gender• Chief Complaint and Functional
LimitationsLimitations• Patient's Rehabilitation Goal(s)
“… Stop squirming, Mr. Silcox. The sooner we fill out these forms, the sooner we’ll fi d t tl h t’ ith ”find out exactly what’s wrong with you.”
subjective evaluation of the knee
Mechanism of Injuryd l t ti t gradual vs. traumatic onset
known vs. insidious cause occupational and/or athletic ADLsoccupational and/or athletic A s
– Frequency– Duration
I t it– Intensity– Recent changes
subjective evaluation of the knee
• Date of Injury
• Date of Surgery– length of immobilization
following surgeryfollowing surgery– type of immobilization following
surgery – weight bearing status– weight bearing progression
prescription or orders
“Looks to me as if every ligament in your knee has been hideously shredded beyond repair … Then again, it could be just a bruise.”p p again, it could be just a bruise.
subjective evaluation of the knee
• Previous Treatment– what, where, when, by whom?– orthotics, braces, sleeves, etc.?– medications or injections?
OTC NSAIDs– Acetaminophen (Tylenol), Ibuprofen (Advil, Motrin);
Naproxen (Aleve); Aspirin
Prescriptive NSAIDs (Cox‐2 Inhibitor)– Celecoxib (Celebrex) or Lodine
I j i Injections– Hyaluronic Acid; Cortisone; PRP
subjective evaluation of the knee
Present Status . . . better, worse, or same work status pain complaint pain complaint
• location, nature, severity, duration, time, aggravated or relieved by,relieved by,
neurological or effusion complaints crepitation, popping, catching,
locking buckling etclocking, buckling, etc.
subjective evaluation of the knee
Past Medical HistorySYSTEMS REVIEW
– general medical or family history i l t d i j i– previous related injuries
– diagnostic studies• x‐ray, CT scan, MRI, EMG/NCV, arthrography
imaging may reveal pathology but musculoskeletal exam and patient history provides relevancey p
objective knee evaluationtests and measures
OBSERVATION:• General Appearance
– Posture– Weight Bearing Status– Symmetrical AppearanceS f Ti lli ff i h– Soft Tissue swelling, effusion, atrophy, etc.
• Body TypeE d /M /E t hi– Endo/Meso/Ectomorphic
structural abnormalities
Sagittal Plane• Genu Recurvatum• Patella Alta/Baja
Transverse Plane• Femoral Anteversion-Retroversion• Femoral Torsion
structural abnormalities
Frontal Plane AbnormalitiesB L d k S t– Bony Landmark Symmetry
– Coxa Varum/Valgus– Genu Varum/Valgus– Q Angle
30° standing; 90° sittingTibial Varum– Tibial Varum
– Calcaneal Varum/Valgus– Leg Length Discrepancies
structural vs. functional
dermal status
• Incisions• Wounds• ColorColor• Texture
knee outcome scales
Quality of Life Scales SF‐36 to measure physical abilities in context of pain, it lit d h i lvitality, and psychosocial health
knee outcome scales
Condition/Specific ScalesA h i i C di i Arthritic Conditions– Western Ontario MacMaster OA Index (WOMAC)– Knee Injury and OA Outcome Score (KOOS)
Ligamentous Injuries– Lysholm Knee Scoring Scale– Tegner or Marx– International Knee Documentation
Committee’s Evaluation Form (IKDC)
Patellofemoral Disorders– Kujala Anterior Knee Pain Scale
knee outcome scales
Region Specific Scales Lower Extremity Functional Scale (LEFS) Activities of Daily Living Knee y gOutcome Survey
knee range of motion assessment
Active/Passive knee EXTENSION‐FLEXION‐TIBIAL ROTATIONi t i l d k– goniometric landmarks
– patient positioning– expected ROM
Prone Heel Height
Assessment methodology for unilateralflexion contracturesflexion contracturesIntratester Reliability = .98 Intertester Reliability = .94
Mulligan, 1994
Angular (Goniometric) Conversiong ( )Taller Patient: 1° = 1cmShorter Patient: 1.5° = 1cm
end feels
Normal Findings Pathological Variants• Soft tissue approximation
– soft• Capsular
• Muscle‐spasm– rebound
• Boggy – firm
• Bony– Abrupt or hard
– mushy • Internal derangement
– springy • Muscular
– tension
p gy• Empty
• Assessment of pain –resistance sequenceresistance sequence
knee passive range of motion
Normal end feels– FLEXION soft tissue approximation– EXTENSION tissue stretchROTATIONS ti t t h/ l– ROTATIONS tissue stretch/capsular
– AB/ADDUCTION capsular
accessory motion testing of the knee
• Patellar Caudal/Cephalic Glide 7 10 7‐10 mm
• Patellar Medial/Lateral Glide two quadrant glide
• Patellar Tilt hypomobile if patella can not be tilted to
neutral and hypermobile if it can be tilted more than 45°
• Tibiofemoral Ant/Post Glide• Superior Tibfib A/P Glide• Superior Tibfib A/P Glide
Hip/Knee Manual Muscle Tests
Iliopsoas vs. TFL Hip ABD – Gluteus Medius Quadriceps
Hip Adductors Med /Lat Hamstrings
Hip EXT –Gluteus Maximus
position stabilizationHip Adductors Med./Lat. HamstringsMaximus resistance substitutions grading grading
Palpationfor position, tenderness, nodules, swellings, or temperature changes
Anterior• suprapatellar pouch, patella, infra‐patellar tendon, tibial p p p , p , p ,
tubercle, bursae, fat padsPosterior• popliteal space, hamstring tendons, posterolateral and
di lposteromedial cornersMedial• medial condyle, joint space, medial tibial plateau, pes
anserine retinacular structures plicae patellar facetanserine, retinacular structures, plicae, patellar facetLateral • lateral epicondyle, ITB, joint space, fibular head, retinacular
structures, lateral facet
Remember your Fracture Rules
OTTAWA I S U GH
An x‐ray is indicated if any of the following are present within the first 7 days
OTTAWA1. Patient age > 552. Isolated tenderness of the patella3 T d t th h d f th fib l
PITTTSBURGH Mechanism of injury is a blunt
trauma or falland3. Tenderness at the head of the fibula
4. Inability to flex the knee 90°5. Inability to immediately bear weight for 4 steps (regardless of limping)
and Patient < 12 or > 55 Inability to walk 4 weight‐
bearing steps in the emergency 4 steps (regardless of limping) room
Rule Rule SNSN (95% CI)(95% CI) SP (95% CI)SP (95% CI) + LR+ LR ‐‐ LRLR
Ottawa 98.5 (93‐100) 49 (43‐51) 1.93 0.05Ottawa 98.5 (93 100) 49 (43 51) 1.93 0.05Pittsburgh 99 (94‐100) 60 (56‐64) 2.48 0.02
functional movements-abilities
• deep squati b l i• stair ambulation
• unilateral balance• functional movement screen• functional movement screen• functional performance evaluation• Return to sport testing
Gait Assessment
• adequate sagittal plane knee flexion in swing phase to provide toe clearance g p p
• knee near full extension at heel strike• adequate eccentrically controlled knee
flexion during forefoot loading phaseflexion during forefoot loading phase• control of extension at heel raise without
excessive recurvatumf t l l t l f / l• frontal plane control of varus/valgus ‐appropriate Q angle during midstance
• appropriate tibial rotation through t hstance phase
arthrometry of the knee
Circumferential Girth Measurements– 15 ‐20 cm inferior to the mid patella– inferior pole of patella– mid patellap– superior pole of patella– 15‐25 cm superior to the mid patella
reliability in a symptomatic population reliability in a symptomatic population– Intratester ICC = 0.82‐1.00– Intertester ICC = 0.72‐.0.9
Soderberg GL, et al, Phys Ther, 1986
The Bulge Sign to detect mild to moderate swelling
• Milk the suprapatellar pouch in a downward direction
• Move the fluid into theMove the fluid into the medial or lateral patellar recess and tap the bloated area to create a fluid wave
KT-1000 Testing
15, 20 or 30 pound, and manual Lachman's anterior tibial displacement values
KT-1000 Video Clip
Ligamentous Testing
ligament stability grading
• proprioceptive end feel• visual anatomical change• comparison to uninvolved side• individuality• gradingg g
mild (1°) moderate (2°) severe (3°) severe (3°)
Posterior Sag: Gravity Drawer
• patient position allows backward tibial sag in the presence of an injured PCLsag in the presence of an injured PCL
• examiner notes loss of normal tibial tubercle prominence as tibia drops backp p
• potential positions of evaluation include 45 or 90°of hip flexion with the knee flexed 90flexed 90
always check the PCL first
Posterior Instability
• anatomical relationships• active quad• active quad• posterior drawer• external rotation ‐ recurvatum for rotational instability
• High sensitivity (90%) and specificity g y ( ) p y(99%) amongst orthopedic surgeons
Rubenstein, et al AJSM 22:550‐57, 1994
PCL Deficiency Video Clips
Active drawer
Specificity = .97 Sensitivity = .54Rubenstein, 1994
Posterior sag in PCL deficient knee
Posterolateral Instability
PCL Deficient Knee
Posterior Drawer
External Rotation Recurvatum Test
Difficult to li i lelicit unless patient under anesthesia
Dial Test AbnormalAbnormal NormalNormal
Passive tibial ER
> 10‐15º asymmetry is pathological
+ at 30º indicative of t l t l i jposterolateral corner injury
+ at 90º indicative of posterolateral cornerposterolateral corner and PCL injury
Reverse Pivot Shift
Testing for Anterior Cruciate Ligament Injury
Lachman’s Test
grasp upper tibia with same hand as ti t’ i l d kpatient’s involved knee
thumb placed at the flare of the tibia other hand grasps the distal femur just other hand grasps the distal femur just proximal to the patella with knee flexed to 20‐30˚ tibia drawn forward and the amount of anterior displacement is gauged and compared to the uninvolved extremitycompared to the uninvolved extremity
Lachman’s Test Video Clip
LACHMAN’S TESTInterpretation of Findings
sensemm anterior excursion of tibia as compared to uninvolved side ( > 3 mm)compared to uninvolved side ( > 3 mm) “end feel”
firmness of endpoint to motionfirmness of endpoint to motion soft or mushy vs. firm
“see” anterior translation and losssee anterior translation and loss of normal patellar tendon slope
Lachman’s Test Grading
Grade I: proprioceptive appreciation of soft end feel
Grade II: visible anterior translation of tibia with soft endpoint
Grade III: passive anterior subluxation of tibia with patient in supine and support under the proximal tibiasupine and support under the proximal tibia
Grade IV: ability of patient to actively sublux the proximal tibia
Grade I‐III a/b: 0‐5 5‐10 10+ with or without firm end feel0‐5, 5‐10, 10+ with or without firm end feel
Lachman’s Test Advantages
1. swelling and guarding do no prevent positioning of knee2. hamstring line of pull not as effective at limiting anterior
translation3 meniscal chock block wedge not as effective at preventing3. meniscal chock block wedge not as effective at preventing
forward displacement4. well established in literature
30˚ flexion
90˚ flexion
Lachman’s Test Disadvantages
1. requires large hands or small thigh
2. supine positioning allows posterior displacement of tibia
f l bl h d l d3. false negatives possible with displaced bucket handle tears of medial meniscus or if excessive tibial internal rotation is applied during the test
Alternate Testing Indications
Prone Position Testing
• thigh girth 8 cm proximal to joint line is more than twice the size of th h dthe hand span
• suspicion of PCL injury
Prone Lachman’s Test Technique
patient in prone position with knee flexed 20‐30° and the leg supported by examiner’s kneeleg supported by examiner s knee
examiner’s opposite hand of the patient’s involved leg palpates the anterior joint margin with fingers on either p p j g gside of the patellar tendon
examiner’s same hand of the ti t’ i l d l lipatient’s involved leg applies
anterior stress on the posterior proximal aspect of the gastroc
Prone Lachman Video Clip
Anterior Drawer Test
Anterior Drawer Test Disadvantages
tense hemarthrosis prevents knee from comfortably obtaining 90˚ flexioncomfortably obtaining 90 flexion
protective hamstring spasm may alter resultsresults
meniscal wedging which masks instability
potential for false negative if PCL screen is not completed prior to testing
Clinical Recognition of ACL Tear
Diagnostic Accuracy
Test SN95% CI
SP95% CI
+ LR ‐LR DOR NND Context
Drawer Test(chronic only)
52‐58 90‐94 6 .49 14 2.1 1 of 2 correct
Pivot Shift 24‐61 97‐98 14 .43 54 2.5 2 of 5 correctLachman 85‐87 91‐94 11 .15 76 1.3 3 of 4 correctProne Lachman 70 97 20 .32 69 1.5 2 of 3 correctMRI 87 95 17 18 127 1 2 4 f 5MRI 87 95 17 .18 127 1.2 4 of 5 correctBenjaminise, JOSPT, 2006 , Scholten, J Fam Pract, 2003, Jackson, Ann Int Med, 2003; Mulligan; JOSPT, 2011
Significant probability shift
ACL Injury Suspicion
Effusion, popping at time of injury, d i i l iand giving way complaint
– 2 of 3 present = + LR of 2.5
– Adding + Lachman’s test increased + LR to over 4Wagemakers HP, et al, Arch Phys Med Rehabil, 2010
Pivot Shift Tests
Patient Complaint: description of “giving way” or “slipping” sensation that occurs withdescription of giving way or slipping sensation that occurs with
cutting or deceleration activities
Clinical Phenomena: anterior subluxation of the lateral tibial plateau when the knee anterior subluxation of the lateral tibial plateau when the knee
approaches full extension, followed by a sudden reduction of the tibia as the knee approaches 30‐40º of flexion
“thud”, “jerk”, or “slip” ‐ this sensation typically reproduces the patient’s l i t f i t bilitcomplaint of instability
Relevance Probably the best test to predict functional outcomes and
possibly premature OA changes
LOSEE PIVOT SHIFT TEST MECHANICSknee passively flexed from full extension with internal tibial torque and valgus stress on the knee
(‐) none (+) glide (++) clunk (+++) gross
Hoshino, Am J Sports Med 2007
Iliotibal band orientation relative to flexion-extension axis
Pivot Shift Test Video Clip
Common Pivot Shift Tests
Hughston Jerk Testg
Slocum Test
The Losee Test The Losee Test
The MacIntosh Test
Noyes Flexion‐Rotation‐Drawer Test
Losee Test
Flexion-Rotation-Drawer Test
Flexion from (A) to (B) results in posterior reduction of subluxed tibia and internal rotation of femurof subluxed tibia and internal rotation of femur
ACL Examination Summary
SN SP − LR + LR
Lachman’s 0 81 0 81 0 23 4 3Lachman s 0.81 0.81 0.23 4.3Pivot Shift 0.28 0.81 0.88 1.1Drawer 0.38 0.81 0.76 1.3van Eck CF, Knee Surg Sports Trumatol Arthrosc, 2013
• Supine Lachman is gold standard• Comparable specificity on all exam techniques• Comparable specificity on all exam techniques• Pivot Shift has greatest specificity• Prone Lachman good alternative for large thighs/small hands
Collateral Ligament Testing
• at 30° flexionValgus Stress – primary restraint
• MCL– secondary restraint
Valgus Stress at 30°
• ACL/PCL ‐ capsule• at full extension
– primary restraintprimary restraint • ACL and posteromedial capsule
– secondary restraint • ACL/PCLACL/PCL
Collateral Ligament Testing
• at 30° flexion i i
Varus Stress Varus Stress at 30at 30°°
• primary restraint • LCL
• secondary restraint • ACL/PCL & posterolateral• ACL/PCL & posterolateral
structures• at full extension
• primary restraint• primary restraint • LCL & ACL‐PCL
• secondary restraint • posterolateral structuresposterolateral structures
Varus – Valgus Testing
tibial abduction tibial adduction
Assessing MCL Lesions
1. History indicating traumatic MOI2. Pain with valgus stress at 303. Laxity with valgus stress at 30
+ LR = 6.4 (MRI gold standard)
Kastelein M, et al, Amer J Med, 2008
MENISCAL ENTRAPMENT TESTS:similar to Passler Rotational Grind Testing
Procedure: flexion to extension with tibia:
– externally rotated and valgus stress – internally rotated and valgus stress externally rotated and varus stress– externally rotated and varus stress
– internally rotated and varus stress
A h h h f iAs you move through the range of motion, notewhere and when the patient notes pain or catching‐clicking sensations.
Meniscal Entrapment Test Interpretation Rationale
• Flexion th t i ti f th i i– compresses the posterior portion of the menisci
– catching or locking in flexed positions indicates damage to the posterior meniscal elements
• Extension• Extension – compresses the anterior portion of the menisci – catching or locking in extended positions indicates
damage to the anterior meniscal elementsg
• Tibial Rotation – used to distort the menisci and assist in identifying
the area of the meniscal lesion
Meniscal Entrapment Test Interpretation Rationale
• Varus Stressth di l t t t i– compresses the medial compartment to increase
– catching, clicking, or locking symptoms– may cause stretch pain of meniscal attachments on lateral side of
the jointj
• Valgus Stress– compresses the lateral compartment to increase p p
catching, clicking, or locking symptoms– may cause stretch pain of meniscal attachments
on medial side of the joint
what portion of the menisci is under stress?
posteromedial posterolateralp
Th l TThessaly TestAccuracy Results in non-acute (> 4 wks) patientsKarachalios, et al, J Bone Joint Surg. 2005
Test Accuracy
E M di l M i L t l M i ACL M iExam Medial Meniscus Lateral Meniscus ACL + Meniscus
McMurray’s 78% 84% 72%
Apley’s 75% 82% 59%Joint Line Palpation 81% 89% 80%Thessaly 5 86% 90% 82%Thessaly 20 94% 96% 90%Thessaly 20 94% 96% 90%
Also reported sensitivity, specificity, false positives and negatives for each test
Th l 20Thessaly 20Test Results
Medial Meniscus Lateral Meniscus ACL + Meniscus
S iti it 89% 92% 80%Sensitivity 89% 92% 80%
Specificity 97% 96% 91%
+ LR 29.7 23 8.9
‐ LR .11 .08 .22
Accuracy 94% 96% 90%
• Original study validated by Harrison et al Clin J Sport Med 2009 with SN = 90• Original study validated by Harrison, et al, Clin J Sport Med, 2009 with SN = 90,SP = 98 resulting in LRs of +39 and – 0.09
• However, not validated by Mirzatolooei, et al, Knee, 2009, with SN = 79, SP = 40resulting in insignificant +/‐ LRs in subjects with ACL tears or by Konan S, et al, Knee Surg Sports Traumatol, 2009, who found 60‐80% accuracy
Meniscal Testing Accuracy
Pooled Accuracy Values of Meniscal TestsTEST SN SP + LR ‐ LR DORMcMurray 71 71 2.4 .41 4.5Joint Line Tenderness 63 77 2.7 .59 4.5Apley’s 61 70 2.6 .50 3.4
Di i A f C bi d M i l TDiagnostic Accuracy of Combined Meniscal TestsTEST SN SP + LR ‐ LR ApplicationJLT + McMurray’s (medial) 91 91 10.1 .10
Better for acute injuriesJLT + McMurray’s (lateral) 75 99 75 25JLT + McMurray s (lateral) 75 99 75 .25JLT + Thessaly (medial) 93 92 11.6 .08
Better for older injuriesJLT + Thessaly (lateral) 78 99 78 .22
No single test has adequate diagnostic accuracy to stand alone as a definitive test for i l l i S i l t t bi ti d d t i d t timeniscal lesions. Special test combinations are needed to improve detection.
McLeod TV, NATA News Clinical Bottom Line, 2011
Other Meniscal Provocative Maneuvers
Joint Line TendernessO’Donohue– O Donohue
– Bragard– Steinmann– Payr’sPayr s – Cabot’s Popliteal sign
Symptom Reproduction– ApleyApley– Bohler and Kromer– Duck Walking (Childress Sign)– Helfet– Ege
Ege’s Testpain or click reproduced at joint line
Medial MeniscalProvocationProvocation Squatting in Ext. Rot.+ LR = 3.5LR 0 41‐ LR = 0.41
Lateral MeniscalProvocationProvocation Squatting in Int. Rot.+ LR = 6.4LR = 0 40‐ LR = 0.40
5 Item Clinical Composite to RULE IN Meniscal Tears
1. Patient history of “catching” or “locking”i i h f d h i2. Pain with forced hyperextension
3. Pain with maximal flexion4 McMurray Sign (“pop” and pain)4. McMurray Sign ( pop and pain)5. Joint line Tenderness
when all present: + LR = 11 5when all present: + LR = 11.5Lowery, Arthroscopy, 2006
MRI vs. Clinical Exam Accuracy
Clinical Exam = MRIin identifying of meniscal lesions Clinical exam generally a little more
haccurate with acute injuries in younger patients while MRI generally more accurate for degenerative lesionsg
Ryzewicz, et al, Clin Ortho Rel Res, 2007
Variable ICC or Kappa
A – Ham Length (°) .92
B – Patellar Tilt Test (norm vs. tight)
.71
C – Q Angle (°) .70
D – Tibial Torsion (°) .70
E – Quad Flex (°) .91E Quad Flex ( ) .91
F – Craig’s Test (°) .45
G – Gastroc Length (°) .92
G – Soleus Length (°) .86
H – Hip ER MMT (kg) .79
I Hi Abd MMT (k ) 85I – Hip Abd MMT (kg) .85
J – Ober’s Test (°) .97
K – Navicular Drop Test (mm) .93
Piva SR, et al. 2006, BMC Musculoskeletal Disorders
p ( ) .93
Apprehension Test
patient is supine with the knee in less than 30° of flexion
examiner places the thumbs along the medial patellarexaminer places the thumbs along the medial patellar border and applies a laterally directed force
apprehension or sudden quad contraction to align the patella constitutes a positive testpatella constitutes a positive test
Questionable value due to low LRs – poor sensitivity but some specificity
patellofemoral tests
Clarke's – pain with quad contraction– pain with quad contraction– SN = 0.39, SP = 0.67, + LR = 1.18, ‐ LR = 0.91
Waldron’ssymptom reproduction with DKB– symptom reproduction with DKB
Wilson’s– OCD reproduced with passive knee extension in IR
ll bili lPatellar Mobility Cluster – Patellar medial/lateral glide, Patellar superior‐inferior glide,
patellar tendon mobility, and absent inferior pole tiltmoderate Kappa reliability and levels of accuracy– moderate Kappa reliability and levels of accuracySweitzer BA, et al, Phys Sportsmed, 2010
PFPS Tests: Diagnostic Accuracy
Validity of 5 Clinical Tests for the diagnosis of PFPS
Test +LR ‐ LR
Vastus Medialis Coordination Test (TKE) 2.3 0.90
Patellar Apprehension Test 2.3 0.79
Waldron Test (NWBing Knee Flexion) 1.4 0.81
Waldron Test (WBing Squat) 1.1 0.99
Clarke’s test 1 9 0 69Clarke’s test 1.9 0.69
Eccentric Step Down Test 2.3 0.71Nijs J, et al, Man Ther, 2006
Importance of Cluster Findings
Squatting is the only individual finding with ability to moderately shift probability of presence or absence of PFPSshift probability of presence or absence of PFPS
Finding SP SN + LR ‐ LR
Squatting 91 50 5.5 .18
Stair Climbing 75 43 1.7 .76
Kneeling 84 50 3.1 .32
Prolonged Sitting 72 57 2.0 .60
Pain with quad contraction, pain with palpation of facets, and pain during squatting had + LR of 4 when at least 2 of 3 were present
g g
Cook C, et al, Physiother Can, 2010