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