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Knee Physical Exam

   Lachman Test

Lachman (Torg JS, Am J Sports Med. 1976;4:84-93)

best test for ACL laxity.  Knee placed in 20-30 degress of flexion, the femur is stabilized, and an anteriorly directed force  applied to proximal calf.    Compare to uninjured side. Grade 1+ = 1-5mm increased translation; 2+= 6-10mm ; 3+=>10mm.

  Pivot Shift

Confirms complete ACL tear. Based on very early flexion causing anterior subluxation of the tibia that is reduced with further flexion (20-40 degrees) due to the posterior pull of the iliotibial tract.  Relocation event graded as 0(absent), 1+ (pivot glide), 2+(pivot shift), 3+(momentary locking) (Galway HR, JBJS 1972;54Br:763)

knee posterior drawer test Posterior Drawer
  • Most accurate test for PCL tear.
  • Patient in supine postion with knee flexed 90°.
  • Palpate the medial tibial plateau and appreciate its position relative to the medial femoral condyle.
  • Apply a posteriorly directed force to proximal tibia.
  • Note the change in the distance (the step-off) from the medial tibial plateau and medial femoral condyle.

Figure: Normal Posterior Drawer
Step-off between medial femoral condyle and medial tibial plateau is maintained when posteriorly directed force is applied to proximal tibia.

  1. Medial femoral condyle
  2. Medial tibial plateau

positive knee posterior drawer

Posterior Drawer
  • Grade I = palpable but diminished stepoff (0-5mm).
  • Grade II = lost their stepoff, but the medial tibial plateau cannot be pushed beyond the medial femoral condyle (5-10mm). 
  • Grade III = complete PCL injuries stepoff is lost, and the tibia can be pushed beyond the medial femoral condyle (>10mm) and has an obvious positive posterior sag.

Figure: Grade II Posterior Drawer
Step-off between medial femoral condyle and medial tibial plateau is lost (5-10mm of subluxation) when posteriorly directed force is applied to proximal tibia.

  1. Medial femoral condyle
  2. Medial tibial plateau
  Quadriceps Active Test
  Dial Test(Tibial External Rotation):
  • Prone postion. Measure thigh-foot angle with external rotation stress applied both at 30° and 90°. Compare to normal side. External rotation of the tibia >10° compared to normal side indicates posterolateral corner injury. Increased ER at 30° but not at 90° indicates isolated posterolateral corner injury. Increased ER at both 30° and 90° indicates combined PLC, PCL injury. (Bleday RM, Arthroscopy 1998;14:489-94) (Larsen MW, J Knee Surg 2005;18:146-50).
 

Valgus Laxity

  • Indicates MCL injury or posteromedial corner injury. 
 

Varus Laxity

  McMurray test
  • patient lying supine with the hip and knee flexed 90°. Apply axial compression while ER and IR the leg.
  • Reproduction of pain +/- clicking indicates meniscal tear.
  Posterolateral external rotation test
  • Posterior tanslation and external rotation forces are applied to the knee at 30° of flexion. Posterolateral subluxation of the proximal tibia indicates PLC injury.
  External rotation recurvatum test
  • Lift the patients extended leg by the great toe and observe for any side to side differences in hyperextension, varus and tibial external rotation. (Hughston JC, CORR 1980;147:82-7).
  Posterolateral drawer test
  • (Hughston JC, CORR 1980;147:82-7), adduction stress test, dynamic posterior shift test, Reverse pivot shift test.
  Anterior drawer test -

anterior force applied at 90 degrees of  flexion.  Least reliable.

  Ege's Test
  • Place feet 8-10 inches appart with feet pointed outward (medial meniscus) or inward (lateral meniscus.
  • Patient squates down with feet flat of the floor. Pain or a click when the knee approaches 90 indicates meniscal tear.
  • 71% accuracy, 67% sensitivity, 81% specificity for medial meniscal lesions (Akseki D, Arthroscopy, 2004;20:951).
  Apley Compression Test

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