SPECIAL TESTS OF THE KNEE & THIGH
Special tests are techniques performed by clinicians. The use of these tests assists in gathering critical information leading to, confirming, ruling out, and monitoring the status of a specific condition. They're a generally reliable way to gain knowledge of the integrity of soft tissue as well as bony structures in the human body.
* Visit the website below to see a video instruction of how to perform any the special tests listed on this page
http://ahn.mnsu.edu/athletictraining/spata/kneemodule/specialtests.html
http://ahn.mnsu.edu/athletictraining/spata/kneemodule/specialtests.html
Ballotable Patella-
- Test Positioning- The subject lies supine with both knees fully extended. The examiner stands with the proximal hand over the suprapatellar pouch and the distal hand (thumb or first two fingers) over the patella.
- Action- Compress the suprapatellar pouch with the proximal hand, then compress the patella into the femur.
- Positive Finding- Downward movement of the patella followed by a rebound will give the appearance of a floating or ballotable patella and is indicative of moderate to sever joint effusion. Comparing bilateral will help determine severity.
Patellar Apprehension Test-
- Test Positioning- The subject lies supine with both knees fully extended. The examiner will stand opposite the involved side and place both thumbs on the medial border of the patella being tested.
- Action- The subject must remain relaxed with no quadriceps contraction, while the examiner gently pushes the patella laterally.
- Positive Finding- If the subject is apprehensive to this movement or contracts the quadriceps muscle to protect against subluxation, the test is indicative of patellar subluxation or dislocation (possibly due to laxity of the medial retinaculum). Also note the patients face and any apprehension that they may display with the movement.
Ballotable Patella-
- Test Positioning- The subject lies supine with both knees fully extended. The examiner stands with the proximal hand over the suprapatellar pouch and the distal hand (thumb or first two fingers) over the patella.
- Action- Compress the suprapatellar pouch with the proximal hand, then compress the patella into the femur.
- Positive Finding- Downward movement of the patella followed by a rebound will give the appearance of a floating or ballotable patella and is indicative of moderate to sever joint effusion. Comparing bilateral will help determine severity.
Sweep Test-
- Test Positioning- The subject lies supine with the involved knee in full extension. The examiner places both hands on the medial aspect of the patella.
- Action- The examiner attempts to "sweep" any intracapsular swelling by applying pressure to the proximal, distal, and lateral aspects of the patella.
- Positive Finding- Fluid that accumulates on the medial aspect of the patella is representative of intracapsular swelling. This can be present as a result of damage to any internal capsular structure.
Q-angle Test-
- Test Positioning- The subject lies supine with the hips and knees extended.
- Action- Identify the anterior superior iliac spines, midpoint of the patella, and the tibial tubercle. Make a line from the ASIS' to the midpoint of the patella, and from the tibial tubercle to the midpoint of the patella. Place a goniometer on the knee such that the axis is over the midpoint of the patella, the proximal arm is over the line to the ASIS', and the distal arm is over the line to the tibial tubercle. The resultant angle is the Q-angle.
- Positive Finding- Q-angle norms with the knee in extension are 13 degrees for males and 18 degrees for females. Angles either greater than or less than these norms may be indicative of patellofemoral pathology.
Medial-Lateral Grind Test-
- Test Positioning- The subject lies supine. The examiner stands next to the involved side and holds the subject's foot. The examiner's other hand is placed over the joint line of the knee.
- Action- The examiner passively flexes the subject's hip and knee maximally and then applies a circular motion with the tibia, rotating the tibia clockwise and counter-clockwise.
- Positive Finding- Pain, grinding, or clicking is indicative of a meniscal tear. Varus or valgus stress may also be simultaneously applied by the hand over the joint line as the knee is passively extended.
Bounce Home Test-
- Test Positioning- The subject lies supine. The examiner stands next to the involved side and cups the subject's foot in one hand. The examiner's other hand may be placed over the joint line of the knee.
- Action- The examiner passively flexes the subject's knee and then allows the knee to passively fall into extension.
- Positive Finding- A rubbery end-feel or springy block is indicative of a meniscal tear. Special caution should be used if a meniscal tear is suspected as it may not be comfortable for the patient and may potentially cause further internal damage.
Patellar Grind Test (Clarke's Sign)-
- Test Positioning- The subject lies supine with the knees extended. The examiner stands next to the involved side and places the web space of the thumb on the superior border of the patella.
- Action- The subject is asked to contract the quadriceps muscle while the examiner applies downward and inferior pressure on the patella.
- Positive Finding- Pain with the movement of the patella or an inability to complete the test is indicative of chondromalacia patella. This test may be painful even for healthy subjects, therefore bilateral comparison is important.
Renne Test-
- Test Positioning- The subject stands. The examiner stands in front of the subject and places the thumb over the lateral epicondyle of the involved knee.
- Action- The subject is instructed to support the body weight on the involved foot and actively flex the knee as if performing a squat. The examiner maintains pressure with the thumb over the lateral epicondyle.
- Positive Finding- If pain is present under the examiner's thumb when the subject's knee is positioned in 30 degrees of flexion, iliotibial band friction syndrome is indicated.
Noble Test-
- Test Positioning- The subject lies supine with the knee flexed to 90 degrees. The examiner stands on the involved side and places the thumb over the lateral epicondyle of the involved knee. The other hand is placed around the subject's ankle.
- Action- The examiner passively flexes and extends the subject's knee while maintaining pressure over the lateral epicondyle.
- Positive Finding- If pain is present under the examiner's thumb when the subject's knee is positioned in 30 degrees of flexion, iliotibial band friction syndrome is indicated.
Houghston's Plica Test-
- Test Positioning- The subject lies supine with the involved knee extended and relaxed. The examiner stands on the involved side and places the heel of one hand over the lateral border of the patella, with the fingers of that hand positioned over the medial femoral epicondyle. The examiner's other hand is placed around the subject's ankle and foot.
- Action- The examiner passively flexes and extends the subject's knee while simultaneously internally rotating the tibia and pushing the patella medially.
- Positive Finding- Pain and/or popping over the medial aspect of the knee is indicative of an abnormal plica. Plica bands may be present and asymptomatic in an otherwise healthy individual. Thus, the location of the band will determine whether or not patella tracking will be affected. Be careful to note that aggressively approaching this procedure may lead to further irritation of the structure.
Godfrey 90/90 Test-
- Test Positioning- The subject lies supine on a table with both the hip and knee of involved side flexed to 90 degrees.
- Action- The examiner passively stabilizes the positioning of the subject's hip and knee while assessing the location of the tibia along the longitudinal axis.
- Positive Finding- The recognition of one tibia resting more inferiorly than the contralateral side may indicate a posterior sag or instability. This must be compared bilaterally and may be related to the posterior cruciate ligament.
Posterior Sag Test-
- Test Positioning- The subject lies on a table with the involved knee flexed to 90 degrees and the ipsilateral hip placed in 45 degrees of flexion.
- Action- The examiner observes the position of the tibia relative to the femur in the sagittal plane. the examiner then instructs the subject to actively contract the quadriceps muscle group in an attempt to extend the knee while retaining hip flexion. The ipsilateral foot should remain fixated to the table during the attempted knee extension.
- Positive Finding- Posterior displacement of the tibia upon the femur while the subject's quadriceps remain silent indicates a posterior instability. This may be reflective of injury to any of the following structures: posterior cruciate ligament, arcuate ligament complex, and posterior oblique ligament. It is important for the examiner to identify a neutral tibiofemoral joint position to avoid misinterpretation.
Reverse Pivot Shift-
- Test Positioning- The subject lies supine with the test knee in 40-45 degrees of flexion. The examiner stands with the proximal hand on the subject's posterolateral leg, just distal to the patella, with the thumb on or anterior to the fibular head. The distal hand grasps the subject's midfoot and heel.
- Action- The examiner externally rotates the tibia with one hand and applies valgus force with the other hand while slowly extending the knee.
- Positive Finding- This is first seen when the examiner flexes the subject's knee if the lateral tibial plateau subluxes posteriorly. Furthermore, this subluxation is reduced once the knee extends and approaches a position of approximately 20 degrees of flexion. At this point, the lateral tibial plateau will return to a neutral position. A palpable "clunk" or shift as it approaches extension (about 20-30 degrees of flexion) is indicative of posterolateral rotary instability secondary to damage of primarily the PCL, LCL, posterolateral capsule, and arcuate complex.
Lachman's Test-
- Test Positioning- The subject lies supine with the test knee flexed to 20-30 degrees. The examiner stands with the proximal hand on the subject's distal thigh (laterally) immediately proximal to the patella, and the distal hand on the subject's proximal tibia (medially) immediately distal to the tibial tubercle.
- Action- From a "neutral" (anterior-posterior) position, apply an anterior force to the tibia with the distal hand while stabilizing the femur with the proximal hand.
- Positive Finding- Excessive anterior translation of the tibia as compared to the uninvolved knee with a diminished or absent end-feel is indicative of a partial or complete tear of the anterior cruciate ligament (ACL).
Anterior Drawer Test-
- Test Positioning- The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and foot in neutral position. The examiner sits on the subject's foot with both hands behind the subject's proximal tibia and thumbs on the tibial plateau.
- Action- Apply an anterior force to the proximal tibia. The hamstring tendons should be palpated frequently with index fingers to ensure relaxation.
- Positive Finding- Increased anterior tibial displacement as compared to the uninvolved side is indicative of a partial or complete tear of the ACL. This procedure may result in a less accurate finding than that found with Lachman's as a result of hamstring tension, as well as posterior sag if present (producing a false-positive finding).
Slocum Test with Internal Tibial Rotation-
- Test Positioning- The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and tibia internally rotated 15-20 degrees. The examiner sits on the subject's foot with both hands behind the subject's proximal tibia and thumbs on the tibial plateau.
- Action- Apply an anterior force to the proximal tibia. The hamstring tendons should be palpated frequently with the index fingers to ensure relaxation.
- Positive Finding- Increased anterior tibial displacement, particularly of the lateral tibial condyle, as compared to the uninvolved side is indicative of anterolateral rotary instability (secondary to a partial or complete tear of primarily the ACL and posterolateral capsule).
Slocum Test with External Tibial Rotation-
- Test Positioning- The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and tibia externally rotated to 15-20 degrees. The examiner sits on the subject's foot with both hands behind the subject's proximal tibia and thumbs on the tibial plateau.
- Action- Apply an anterior force to the proximal tibia. The hamstring tendons should be palpated frequently with the index fingers to ensure relaxation.
- Positive Finding- Increased anterior tibial displacement, particularly of the medial tibial condyle, as compared to the uninvolved side is indicative of anteromedial rotary instability secondary to damage to primarily the medial collateral ligament (MCL), ACL, and posteromedial capsule.
Pivot Shift Test-
- Test Positioning- The subject lies supine with the test knee in full extension. The examiner stands with the proximal hand on the subject's anterolateral tibiofemoral joint, with the thumb on or posterior to the fibular head. The distal hand grasps the subject's midfoot and heel.
- Action- Internally rotate the tibia with the distal hand, apply a valgus force with the proximal hand, and slowly flex the knee.
- Positive Finding- A palpable "clunk" or shift at about 20-30 degrees of flexion is indicative of anterolateral rotary instability secondary to tearing of the ACL and posterolateral capsule.
Posterior Drawer Test-
- Test Positioning- The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and foot in neutral position. The examiner sits on the subject's foot with both hands behind the subject's proximal tibia and thumbs on the tibial plateau.
- Action- Apply a posterior force to the proximal tibia.
- Positive Finding- Increased posterior tibial displacement as compared to the uninvolved side is indicative of a partial or complete tear of the PCL. Remember to encourage the patient to maintain quadriceps and hamstring muscle relaxation.
Posterior Lachman's Test-
- Test Positioning- The subject lies supine with the test knee flexed to 20-30 degrees. The examiner stands with the proximal hand on the subject's distal thigh (laterally) immediately proximal to the patella and the distal hand on the subject's proximal tibia (medially) immediately distal to the tibial tubercle.
- Action- From a "neutral" (anterior-posterior) position, apply a posterior force to the tibia with the distal hand while the femur is stabilized with the proximal hand.
- Positive Finding- Excessive posterior translation of the tibia (as compared to the uninvolved knee) from a neutral position with a diminished or absent end-feel is indicative of a partial or complete tear of the posterior cruciate ligament.
Valgus Stress Test-
- Test Positioning- The subject lies supine with the knee in full extension. The examiner stands with the distal hand on the subject's medial ankle and the proximal hand on the knee.
- Action- With the ankle stabilized, apply a valgus force at the knee with the proximal hand. This is performed with the knee in full extension and repeated with the knee in 20-30 degrees of flexion.
- Positive Finding- Medial knee pain and/or increased valgus movement with a diminished or absent end-feel as compared to the uninvolved knee is indicative of damage to primarily the MCL, PCL, and posteromedial capsule when found in extension, and MCL when tested in 20-30 degrees of flexion. Avoid allowing the femur to internally or externally rotate.
Varus Stress Test-
- Test Positioning- The subject lies supine with the knee in full extension. The examiner stands with the distal hand on the subject's lateral ankle and the proximal hand on the knee (medially).
- Action- With the ankle stabilized, apply a varus force at the knee with the proximal hand. This is performed with the knee in full extension and repeated with the knee in 20-30 degrees of knee flexion.
- Positive Finding- Lateral knee pain and/or increased varus movement with a diminished or absent end-feel as compared to the uninvolved knee is indicative of damage to primarily the LCL, PCL, and arcuate complex when found at full extension, and LCL when tested at 20-30 degrees of flexion.
McMurray Test-
- Testing Position- subject lies supine as the examiner stands with the distal hand grasping the subject's distal leg, and the proximal hand on the subjects knee with fingers palpating the medial and lateral joint lines
- Action- With knee fully flexed, externally rotated the tibia, introduce a valgus force and extend the knee. Repeat this process with tibia internally rotated and a varus force applied to the knee
- Positive Finding- A "click" along the medial joint line is indicative of a medial meniscus tear and vice versa.
Apley Compression Test-
- Testing Position- the subject lies prone with the test knee flexed to 90 degrees. The examiner stands with the proximal hand on the subject's distal thigh to stabilize as the distal hand is placed on the subject's heel.
- Action- With distal hand, medially and laterally rotate the tibia while applying a downward force through the heel (the test may be repeated with a distraction force)
- Positive Finding- Pain, clicking, and/or restriction is indicative of either a medial or lateral meniscus tear, depending on the location of symptoms
(Konin et al. 2006)