KNEE

SPECIAL TESTS

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE MEDIAL INSTABILITY

Abduction (valgus stress) testPROCEDURE• examiner applies a valgus stress (pushes the knee

medially) at the knee while the ankle is stabilized in slight lateral rotation either with the hand or with the leg held between the examiner's arm and trunk. The knee is first in full extension, and then it is slightly flexed (20° to 30°) so that it is "unlocked."

POSITIVE TEST• the tibia moves away from the femur an excessive

amount

Hughston's valgus stress testPROCEDURE• examiner faces the patient's foot, placing his or her

body against the patient's thigh to help stabilize the upper leg in combination with one hand, which can also palpate the joint line. With the other hand, the examiner grasps the patient's big toe and applies a valgus stress, allowing any natural rotation of the tibia

POSITIVE TEST• the tibia moves away from the femur an excessive

amount

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE LATERAL INSTABILITY

Adduction (varus stress) testPROCEDURE• The examiner applies a varus stress (pushes the

knee laterally) at the knee while the ankle is stabilized. The test is first done with the knee in full extension and then with the knee in 20° to 30° of flexion.

POSITIVE TEST• the tibia moves away from the femur when a

varus stress is applied

Hughston's varus stress testPROCEDURE• The examiner grasps the fifth and fourth toes and

applies a varus stress to the knee in extension and slightly (20° to 30°) flexed.

POSITIVE TEST• the tibia moves away from the femur when a

varus stress is applied

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE ANTERIOR INSTABILITY

Lachman TestPROCEDURE• patient lies supine with the involved leg beside the

examiner. The examiner holds the patient's knee between full extension and 30° of flexion. patient's femur is stabilized with one of the examiner's hands (the "outside" hand) while the proximal aspect of the tibia is moved forward with the other ("inside") hand.

POSITIVE TEST• "mushy" or soft end feel when the tibia is moved

forward on the femur• disappearance of the infrapatellar tendon slope

Modification 1

PROCEDURE• The patient is sitting with the leg over the edge of

the examining table. The examiner sits facing the patient and supports the foot of the test leg on the examiner's thigh so that the patient's knee is flexed 30°. The examiner stabilizes the thigh with one hand and pulls the tibia forward with the other hand.

POSITIVE TEST• Abnormal forward motion

Modification 2Stable Lachman test

PROCEDURE• The patient lies supine with the knee resting on

the examiner's knee. One of the examiner's hands stabilizes the femur against the examiner's thigh, and the other hand applies an anterior stress

POSITIVE TEST• Abnormal forward motion of tibia

Modification 3Drop leg Lachman test

PROCEDURE• The patient lies supine, and the leg to be

examined is abducted off the side of the examining table and the knee is flexed to 25°. One of the examiner's hands stabilizes the femur against the table while the patient's foot is held between the examiner's knees. The examiner's other hand is then free to apply the anterior translation force

Modification 4PROCEDURE• patient lying supine while the examiner

stabilizes the foot between the examiner's thorax and arm. Both hands are placed around the tibia, the knee is flexed 20° to 30°, and an anterior drawer movement is performed.

Modification 5PROCEDURE• patient to lie supine while the examiner

stands beside the leg to be tested with the eyes level with the knee. The examiner grasps the femur with one hand and the tibia with the other hand. The tibia is pulled forward

• abnormal motion is noted

Modification 6 – Prone Lachman TestPROCEDURE• the patient lies prone, and the examiner stabilizes

the foot between the examiner's thorax and arm and places one hand around the tibia. The other hand stabilizes the femur

Modification 7 Active (no touch) Lachman test

PROCEDURE• patient lies supine with the knee over the

examiner's forearm so that the knee is flexed approximately 30°. The patient is asked to actively extend the knee, and the examiner watches for anterior displacement of the tibia relative to the unaffected side.

Modification 8Maximum Quadriceps test

PROCEDURE• The test may be carried out with the foot held

down on the table to increase the pull of the quadriceps.

Drawer SignPROCEDURE• patient's knee is flexed to 90°, and the hip is flexed

to 45°. The patient's foot is held on the table by the examiner's body with the examiner sitting on the patient's forefoot and the foot in neutral rotation. The examiner's hands are placed around the tibia to ensure that the hamstring muscles are relaxed. The tibia is then drawn forward on the femur.

POSITIVE TEST• tibia moves forward more than 6mm on the femur

Active Drawer TestPROCEDURE• patient is positioned as for the normal

drawer test. The examiner holds the patient's foot down. The patient is asked to try to straighten the leg, and the examiner prevents the patient from doing so (isometric test).

POSITIVE• tibia to shift forward to its normal position• (+) torn PCL

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE POSTERIOR INSTABILITY

ONE-PLANE POSTERIOR INSTABILITY

• Drawer Test• Active Drawer Test

Posterior Sag Sign (Gravity Drawer Test)

PROCEDURE• The patient lies supine with the hip flexed to 45°

and the knee flexed to 90°. POSITIVE TEST• tibia "drops back," or sags back, on the femur

because of gravity if the posterior cruciate ligament is torn

Reverse Lachman Test

PROCEDURE• The patient lies prone with the knee flexed to 30°,

and the examiner grasps the tibia with one hand while fixing the femur with the other hand. The examiner ensures that the hamstring muscles are relaxed. The examiner then pulls the tibia up (posteriorly), noting the amount of movement and the quality of the end feel

POSITIVE TEST• Excessive posterior movement

Godfrey (Gravity) Test

PROCEDURE• The patient lies supine, and the examiner holds

both legs while flexing the patient's hips and knees to 90°.

POSITIVE TEST• If there is posterior instability, a posterior sag of

the tibia is seen.

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE ANTEROMEDIAL ROTARY INSTABILITY

Slocum test

PROCEDURE• patient's knee is flexed to 80° or 90°, and the hip

is flexed to 45°. The foot is first placed in 30° medial rotation. The examiner then sits on the patient's forefoot to hold the foot in position and draws the tibia forward.

POSITIVE TEST• movement occurs primarily on the lateral side of

the knee

Lemaire's T drawer testPROCEDURE• second part of the Slocum test, the foot is placed

in 15° of lateral rotation, and the tibia is drawn forward by the examiner.

POSITIVE TEST• the movement occurs primarily on the medial side

of the knee.

Dejour testPROCEDURE• patient lies supine. The examiner holds the patient's

leg with one arm against the body and the hand under the calf to lift the tibia while applying a valgus stress. The other hand pushes the femur down.

POSITIVE TEST• In extension, this action causes anteromedial

subluxation in the pathological knee. If the knee is then flexed, the tibial plateau reduces suddenly, indicating a positive test. If the jolt is painful, it indicates that the medial meniscus has been injured. If it is not painful, the posteromedial corner has been injured.

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE ANTEROLATERAL ROTARY INSTABILITY

ONE-PLANE ANTEROLATERAL ROTARY INSTABILITY

• Slocum Test

Lateral Pivot Shift Maneuver (Test of MacIntosh)

PROCEDURE• The patient lies supine with the hip both flexed and

abducted 30° and relaxed in slight medial rotation (20°). The examiner holds the patient's foot with one hand while the other hand is placed at the knee, holding the leg in slight medial rotation by placing the heel of the hand behind the fibula and over the lateral head of the gastrocnemius muscle with the tibia medially rotated, causing the tibia to subluxate anteriorly as the knee is taken into extension

POSITIVE TEST“giving way”

Active Pivot Shift TestPROCEDURE• patient sits with the foot on the floor in neutral

rotation and the knee flexed 80° to 90°. The patient is asked to isometrically contract the quadriceps while the examiner stabilizes the foot.

POSITIVE TEST• anterolateral subluxation of the lateral tibial

plateau

Losee TestPROCEDURE• patient lies supine while relaxed. The examiner holds

the patient's ankle and foot so that the leg is laterally rotated and braced against the examiner's abdomen. The knee is then flexed to 30°, and the examiner ensures that the hamstring muscles are relaxed

• valgus force is applied to the knee; the examiner uses the abdomen as a fulcrum while extending the patient's knee and applying forward pressure behind the fibular head with the thumb.

POSITIVE TEST• “clunk“ forward before extension

Jerk Test of HughstonPROCEDURE• similar to the pivot shift maneuver.• patient's hip is flexed to 45°. With this test, the

knee is first flexed to 90°. The leg is then extended, maintaining medial rotation and a valgus stress

POSITIVE TEST• subluxation of the lateral tibial plateau with a jerk

at approximately 20° to 30° of flexion

Slocum ALRI TestPROCEDURE• patient is in the side-lying position (approximately

30° from supine). The bottom leg is the uninvolved leg. The knee of the uninvolved leg is flexed to add stability. The foot of the involved leg rests and is stabilized on the examining table with the patient's foot in medial rotation and the knee in extension and valgus. The examiner applies a valgus stress to the knee while flexing the knee.

POSITIVE TEST• subluxation of the knee reduces at between 25° and

45° of flexion

Crossover Test of ArnoldPROCEDURE• patient is asked to cross the uninvolved leg in front

of the involved leg. The examiner then carefully steps on the patient's involved foot to stabilize it and instructs the patient to rotate the upper torso away from the injured leg approximately 90° from the fixed foot. When this position is achieved, the patient contracts the quadriceps muscles

POSITIVE TEST• Reproduction of symptoms similar to lateral pivot

shift test

Noyes Flexion-Rotation Drawer TestPROCEDURE

• Patient lies supine, and the examiner holds the patient's ankle between the examiner's trunk and arm with the hands around the tibia. The examiner flexes the patient's knee to 20° to 30° while maintaining the tibia in neutral rotation. The tibia is then pushed posteriorly, as in a posterior drawer test

• POSITIVE TEST• posterior movement reduces the subluxation of

the tibia

Lemaire's Jolt TestPROCEDURE• patient is in side lying position with the test leg

uppermost. For the test to work, the patient must be relaxed. With one hand, the examiner medially rotates the tibia by grasping the foot and medially rotating it with the knee in extension. The back of the other hand pushes lightly against the biceps tendon and head of fibula while the hand on the foot flexes and extends the knee

POSITIVE TEST• at about 15° to 20° of flexion, a "jolt" occurs with

displacement of the tibia

Flexion-Extension Valgus TestPROCEDURE• patient lies supine, and the examiner holds the

patient's leg as in the Noyes test. The examiner palpates the joint line with the thumb and fingers of both hands, and a valgus stress and axial compression are applied while the knee is flexed and extended

POSITIVE TEST• If the anterior cruciate ligament is torn, the

examiner feels the reduction and subluxation.

Nakajima TestPROCEDURE• patient lies supine, and the examiner stands on the

side of the test leg. The patient's foot is held with one hand, which medially rotates the tibia. The knee is flexed to 90°. The examiner's other hand is placed over the lateral femoral condyle with the thumb behind the head of the fibula pushing it forward. The examiner slowly extends the knee while pushing the head of the fibula forward.

POSITIVE TEST• subluxation

Martens TestPROCEDURE• patient and examiner are positioned as for the

Noyes test. The examiner grips the patient's leg distal to the knee joint with one hand an pushes The femur posteriorly with the other hand. A valgus stress is applied to the knee as the knee is flexed

POSITIVE TEST• Tibia reduces

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE POSTEROMEDIAL ROTARY INSTABILITY

Hughston's Posteromedial and Posterolateral Drawer Sign

PROCEDURE• patient lies supine with the knee flexed to 80° to

90° and the hip flexed to 45°. The examiner medially rotates the patient's foot slightly and sits on the foot to stabilize it. The examiner then pushes the tibia posteriorly.

POSITIVE TEST• tibia moves or rotates posteriorly on the medial

aspect an excessive amount relative to the normal knee

Posteromedial Pivot Shift TestPROCEDURE• Passively flexes the knee more than 45° while

applying a varus stress, compression, and medial rotation of the tibia

POSITIVE TEST• movements cause subluxation of the medial tibial

plateau posteriorly• examiner then takes the knee into extension. At

about 20° to 40° of flexion, the tibia shifts into the reduced position

TESTS FOR LIGAMENTOUS INSTABILITY

ONE-PLANE POSTEROLATERAL ROTARY INSTABILITY

• Hughston's Posteromedial and Posterolateral Drawer Sign.

Jakob Test (Reverse Pivot Shift Maneuver)

PROCEDURE (Method 1)• patient stands and leans against a wall with the

uninjured side adjacent to the wall and the body weight distributed equally between the two feet. The examiner's hands are placed above and below the involved knee, and a valgus stress is exerted while flexion of the patient's knee is initiated.

POSITIVE TEST• jerk in the knee or the tibia shifts posteriorly and

the "giving way" phenomenon

Jakob Test (Reverse Pivot Shift Maneuver)

PROCEDURE (Method 2)• patient lies in supine with hamstrings relaxed. The

examiner faces the patient, lifts the patient's leg, and supports the leg against the examiner's pelvis. The examiner other hand supports the lateral side of the calf with the palm on the proximal fibula. The knee is flexed to 70° to 80° of flexion, and the foot is laterally rotated, causing the lateral tibial plateau to subluxate posteriorly. The knee is taken into extension by its own weight while the examiner leans on the foot to impart a valgus stress to the knee through the leg

POSITIVE TEST• At ~ 20° of flexion, the lateral tibial tubercle

shifts forward or anteriorly into the neutral rotation and reduces the subluxation

• The leg is then flexed again, and the foot falls back into lateral rotation and posterior subluxation.

External Rotation Recurvatum Test

PROCEDURE• patient lies in the supine position with the lower limbs

relaxed. The examiner gently grasps the big toe of each foot and lifts both feet off the examining table. The patient is told to keep the quadriceps muscles relaxed (i.e., it is a passive test). While elevating the legs, the examiner watches the tibial tuberosities.

POSITIVE TEST• affected knee goes into relative hyperextension on the

lateral aspect due to the force of gravity, with the tibia and tibial tuberosity rotating laterally. The affected knee has the appearance of a relative genu varum.

Active Posterolateral Drawer SignPROCEDURE• The patient sits with the foot on the floor in

neutral rotation. The knee is flexed to 80° to 90°. The patient is asked to isometrically contract the hamstrings, primarily the lateral one (biceps femoris), while the examiner stabilizes the foot.

POSITIVE TEST• posterior subluxation of the lateral tibial plateau

Standing Apprehension TestPROCEDURE• The patient stands on the affected knee. The

examiner then pushes anteriorly and medially on the anterolateral part of the lateral femoral condyle crossing the joint line. The patient is then asked to slightly flex the knee while the examiner pushes with the thumb.

POSITIVE TESTCondylar movement and a giving way sensation

MENISCUS LESIONS

McMurray testPROCEDURE• The patient lies in the supine position with the

knee completely flexed (the heel to the buttock). The examiner then medially rotates the tibia and extends the knee. To test the medial meniscus, the examiner performs the same procedure with the knee laterally rotated.

POSITIVE TEST• (+) snap or click that is often accompanied by pain

Apley’s testPROCEDURE• The patient lies in the prone position with the

knee flexed to 90°, thigh stabilized on table with the examiner’s knee. The examiner medially and laterally rotates the tibia, combined first with distraction, then compression.

POSITIVE TEST• (+)rotation plus distraction is more painful or

increased rotation, ligamentous• (+)rotation plus compression is more painful or

shows decreased rotation, meniscus

“Bounce Home” test

PROCEDURE• The patient lies in the supine position, and the

heel of the patient's foot is cupped in the examiner's hand. The patient's knee is completely flexed, and the knee is passively allowed to extend.

POSITIVE TEST• extension is not complete or has a rubbery end

feel ("springy block"),

Thessaly testPROCEDURE• The patient stands flat footed on one leg while

the examiner provides his/her hands for balance. Pt flexes knee to 20 and rotates the femur on the tibia medially and laterally three times while maintaining the 20 flexion. Test first the good leg and then the injured leg.

POSITIVE TEST• Medial or lateral joint line discomfort• Sense of locking or catching in the knee

O’Donohue’s testPROCEDURE• The patient is asked to lie in the supine position.

The examiner flexes the knee to 90°, rotates it medially and laterally twice, and then fully flexes and rotates it both ways again.

POSITIVE TEST• increased pain on rotation in either or both

positions and is indicative of capsular irritation or a meniscus tear.

Modified Helfet TestPROCEDURE• In the normal knee, the tibial tuberosity is in line

with the midline of the patella when the knee is flexed to 90°. When the knee is extended, however, the tibial tubercle is in line with the lateral border of the patella

POSITIVE TEST• If this change does not occur with the change in

movement• (+)meniscal injury, possible cruciate injury, or

quadriceps have insufficient strength to “screw home” the knee

Test for Retreating or Retracting MeniscusPROCEDURE• patient sits on the edge of the examining table or

lies in the supine position with the knee flexed to 90°. The examiner places one finger over the joint line of the patient's knee anterior to the MCL, where the curved margin of the medial femoral condyle approaches the tibial tuberosity. The patient's leg and foot are then passively laterally rotated, and the meniscus normally disappears.

• The leg is medially and laterally rotated several times, with the meniscus appearing and disappearing

POSITIVE TEST• meniscus does not appear• the meniscus can be felt pushing against the

finger on medial rotation, and it disappears on lateral rotation

Steinman's Tenderness Displacement TestPROCEDURE• The Steinman's sign is indicated by point

tenderness and pain on the joint line that appears to move anteriorly when the knee is extended and moves posteriorly when the knee is flexed.

POSITIVE TEST• Medial pain is elicited on lateral rotation• lateral pain is elicited on medial rotation

Payr's TestPROCEDURE• The patient lies supine with the test leg in the

figure-four positionPOSITIVE TEST• pain is elicited on the medial joint line• (+)meniscus lesion, primarily middle and

posterior part

Bohler's SignPROCEDURE• patient lies in the supine position, and the

examiner applies varus and valgus stresses to the knee

POSITIVE TEST• Pain in the opposite joint line (valgus stress

for lateral meniscus

Bragard's SignPROCEDURE• patient lies supine and the examiner flexes

the patient's knee. The examiner then laterally rotates the tibia and extends the knee

POSITIVE TEST• Pain and tenderness on the medial joint line• If the examiner then medially rotates the

tibia and flexes the knee, the pain and tenderness will decrease.

Kromer's SignPROCEDURE• This test is similar to Bohler's sign except

that the knee is flexed and extended while the varus and valgus stresses are applied

POSITIVE TEST• the same pain on the opposite joint line

Childress' SignPROCEDURE• The patient squats and performs a "duck

waddle." POSITIVE TEST• Pain, snapping, or a click for posterior horn

lesion of the meniscus

Anderson Medial-lateral Grind TestPROCEDURE• The patient lies supine. The examiner holds the test

leg between the trunk and the arm while the index finger and thumb of the opposite hand are placed over the anterior joint line. A valgus stress is applied to the knee as it is passively flexed to 45°; then, a varus stress is applied to the knee as it is passively extended, producing a circular motion to the knee. The motion is repeated, increasing the varus and valgus stresses with each rotation

POSITIVE TEST• Distinct grinding

Passler Rotational Grind TestPROCEDURE• The patient sits with the test knee extended and

held at the ankle between the examiner's legs proximal to the examiner's knees. The examiner places both thumbs over the medial joint line and moves the knee in a circular fashion, medially and laterally rotating the tibia while the knee is rotated through various flexion angles. Simultaneously, the examiner applies a varus or a valgus stress

POSITIVE TEST• Pain elicited on the joint line

Cabot’s Popliteal SignPROCEDURE• The patient lies supine, and the examiner

positions the test leg in the figure four position. The examiner palpates the joint line with the thumb and forefinger of one hand and places the other hand proximal to the ankle of the test leg. The patient is asked to isometrically straighten the knee while the examiner resists the movement

POSITIVE TEST• Pain on the joint

PLICA LESIONS

Mediopatellar Plica Test (Mital-Hayden Test)

PROCEDURE• The patient lies in the supine position, and the

examiner flexes the affected knee to 30° resting on a support or the examiner’s arm. Examiner pushes the patella medially with the thumb.

POSITIVE TEST• (+)pain or click

Plica "Stutter" TestPROCEDURE• The patient is seated on the edge of the examining

table with both knees flexed to 90°. The examiner places a finger over one patella to palpate during movement. The patient is then instructed to slowly extend the knee.

POSITIVE TEST• patella stutters or jumps somewhere between 60°

and 45° of flexion (0° being straight leg) during an otherwise smooth movement. The test is effective only if there is no joint swelling.

Hughston's Plica TestPROCEDURE• The patient lies in the supine position, and the

examiner flexes the knee and medially rotates the tibia with one arm and hand while pressing the patella medially with the heel of the other hand and palpating the medial femoral condyle with the fingers of the same hand. The patient's knee is passively flexed and extended

POSITIVE TEST• "popping" of the plical band under the fingers

Patellar Bowstring TestPROCEDURE• The patient in sidelying position with the test leg

uppermost. Using the heel of one hand, the examiner pushes the patella medially and holds it there. The examiner then flexes the patient’s knee and medially rotates the tibia with the other hand. The patient’s knee is then extended.

POSITIVE TEST• Examiner feels any sounds

SWELLING

Brush, Stroke, or Bulge Test (Wipe test)

PROCEDURE• Examiner commences just below the joint line on

the medial side of the patella, stroking proximally toward the patient's hip as far as the suprapatellar pouch two or three times with the palm and fingers. With the opposite hand, the examiner strokes down the lateral side of the patella

POSITIVE TEST• A wave of fluid passes to the medial side of

the joint and bulges just below the medial distal portion or border of the patella. The wave of fluid may take up to 2 seconds to appear.

• test shows as little as 4 to 8 mL of extra fluid (normal is 1-7 mL)

Indentation TestPROCEDURE• The patient lies supine. The examiner passively

flexes the good leg, noting an indentation on the lateral side of the patellar tendon. The good knee is fully flexed, and the indentation remains. The injured knee is then slowly flexed while the examiner watches for the disappearance of the indentation. At that point, knee flexion is stopped

POSITIVE TEST• disappearance of the indentation. The greater the

swelling, the sooner the indentation disappears

Peripatellar Swelling TestPROCEDURE• The patient lies supine with the knee extended. The

examiner carefully milks fluid from the suprapatellar pouch distally. With the opposite hand, the examiner palpates adjacent to the patellar tendon (usually on the medial side) for fluid accumulation or a wave of fluid passing under the fingers. examiner strokes the fluid into the suprapatellar pouch. With one hand, the examiner then squeezes or pushes down on the suprapatellar pouch while watching the hollows on each side of the patella for a wave of fluid to pass

POSITIVE TESTPalpable fluid wave

Fluctuation TestPROCEDURE• The examiner places the palm one hand over

the suprapatellar pouch and the palm the other hand anterior to the joint with the thumb and index finger just beyond the margins of the patella . By pressing down with one hand an then the other

POSITIVE TESTthe examiner may feel the synovial fluid fluctuate under the hands and move from one hand to the other, indicating significant effusion.

Patellar Tap Test ("Ballotable Patella")

PROCEDURE• With the patient's knee extended or flexed to

discomfort, the examiner applies a slight tap or pressure over the patella

POSITIVE TEST• floating of the patella should be felt. This is

sometimes called the "dancing patella" sign

PATELLOFEMORAL SYNDROME

Vastus Medialis Coordination TestPROCEDURE• The patient lies supine while the examiner places

a fist under the patient's knee. The patient is asked to slowly extend the knee without pressing into the examiner's fist or lifting the leg away from the fist while trying to achieve full extension.

POSITIVE TEST• the patient cannot fully extend the knee or has

difficulty achieving full extension smoothly or tries to use the hip flexors or extensors to accomplish the task.

Clarke's Sign (Patellar Grind Test)

PROCEDURE• The examiner presses down slightly proximal to

the upper pole or base of the patella with the web of the hand as the patient lies relaxed with the knee extended. The patient is then asked to contract the quadriceps muscles while the examiner pushes down.

• To test different parts of the patella, the knee should be tested in 30°, 60°, and 90° of flexion as well as in full extension.

POSITIVE TEST• (+)retropatellar pain and the patient• cannot hold a contraction

McConnell Test for Chondromalacia Patellae

PROCEDURE• The patient is sitting with the femur laterally rotated. The

patient performs isometric quadriceps contractions at 120°, 90°, 60°, 30°, and 0°, with each contraction held for 10 seconds. If pain is produced during any of the contractions, the patient's leg is passively returned to full extension by the examiner. The patient's leg is then fully supported on the examiner's knee, and the examiner pushes the patella medially. The medial glide is maintained while the knee is returned to the painful angle, and the patient performs an isometric contraction, again with the patella held medially.

POSITIVE TEST• pain is decreased

Active Patellar Grind TestPROCEDURE• The patient sits on the examining table with the

knee flexed 90° over the edge of the table. While the patient slowly straightens the knee, the examiner places a hand over the patella to feel for crepitus. Where in the ROM that pain occurs will give an indication of what part of the patella is demonstrating pathology. Greater force can be applied through the patella by asking the patient to step up and step down on a small stool

POSITIVE TEST• Crepitus and pain (step up-step down test)

Step Up TestPROCEDURE• The patient stands beside a stool that is 25 cm

(10 inches) high. The examiner asks the patient to step up sideways onto the stool using the good leg. The test is repeated with the other leg.

POSITIVE TESTNormally, the patient should have no difficulty doing the test and have no pain. Inability to do the test may indicate patellofemoral arthralgia, weak quadriceps, or an inability to stabilize the pelvis

Eccentric Step TestPROCEDURE• The patient stands on a 15-cm (6 inch )-high

step or stool while keeping the hands on the hips. The patient steps down, first leading with the injured leg (this tests the good leg first) as slowly and smoothly as he or she can.

POSITIVE TESTThe test is considered positive if pain is felt by the patient

Waldron TestPROCEDURE• The examiner palpates the patella while the patient

performs several slow deep knee bends (these may be unilateral squats or bilateral for easier comparison. As the patient goes through the ROM, the examiner should note the amount of crepitus (significant only if accompanied by pain), where it occurs in the ROM, the amount of pain, and whether there is "catching" or poor tracking of the patella throughout the movement.

POSITIVE TEST• pain and crepitus occur together during the movement

Passive Patellar Tilt TestPROCEDURE• The patient lies supine with the knee extended and

the quadriceps relaxed. The examiner stands at the end of the examining table and lifts the lateral edge of the patella away from the lateral femoral condyle.

POSITIVE TESTThe patella should not be pushed medially or laterally but rather should remain in the femoral trochlea. The normal angle is 15°, although males may have an angle 5° less than that of females. Patients with angles less than this are prone to patellofemoral syndrome

Lateral Pull TestPROCEDURE• The patient lies supine with the leg extended.

The patient contracts the quadriceps while the examiner watches the movement of the patella. Normally, the patella moves superiorly, or superiorly and laterally in equal proportions.

POSITIVE TESTIf lateral movement is excessive, the test is positive for lateral overpull of the quadriceps, resulting in a patellofemoral arthralgia.

Zohler’s SignPROCEDURE• The patient lies supine with the knees

extended. The examiner pulls the patella distally and holds it in this position. The patient is asked to contract the quadriceps

POSITIVE TEST• Pain is indicative for chondromalacia

patellae

Frund’s SignPROCEDURE• The patient is in the sitting position.• The examiner percusses the patella in

various positions of knee flexion. POSITIVE TEST• Pain may signify chondromalacia patellae

QUADRICEPS PULL

Q-Angle or Patellofemoral AnglePROCEDURE• A line is then drawn from the ASIS to the midpoint

of the patella on the same side and from the tibial tubercle to the midpoint of the patella. Normally, the Q-angle is 13° for males and 18° for females when the knee is straight.

POSITIVE TEST• Any angle less than 13° may be associated with

chondromalacia patellae or patella alta. An angle greater than 18°

• is often associated with chondromalacia patellae, subluxing patella, increased femoral anteversion, genu valgum, lateral displacement of tibial tubercle, or increased lateral tibial torsion

Tubercle Sulcus Angle (Q-Angle at 90°)PROCEDURE• A vertical line is drawn from the center of the

patella to the center of the tibial tubercle. A second horizontal line is drawn through the femoral epicondyle. Normally the lines are perpendicular

POSITIVE TEST• Angles greater than 10° from the perpendicular

are considered abnormal. Lateral patellar subluxation may affect the results.

OSTEOCHONDRITIS DISSECANS

Wilson TestPROCEDURE• The patient sits with the knee flexed over the

examining table. The knee is then actively extended with the tibia medially rotated. At approximately 30° of flexion (0° being straight leg), the pain in the knee increases, and the patient is asked to stop the flexion movement. The patient is then asked to rotate the tibia laterally, and the pain disappears.

POSITIVE TESTPain increases on the first part of the procedure and decreases on the latter

PATELLAR INSTABILITY

Fairbank's Apprehension TestPROCEDURE• The patient lies in the supine position with the

quadriceps muscles relaxed and the knee flexed to 30° while the examiner carefully and slowly pushes the patella laterally

POSITIVE TEST• If the patient feels the patella is going to dislocate,

the patient will contract the quadriceps muscles to bring the patella back "into line.” Patient will also have an apprehensive look.

ILIOTIBIAL BAND FRICTION SYNDROME

Noble Compression TestPROCEDURE• The patient lies in the supine position, and the

examiner flexes the patient's knee to 90°, accompanied by hip flexion. Pressure is then applied to the lateral femoral epicondyle, or 1 to 2 cm (0.4 to 0.8 inch) proximal to it, with the thumb. While the pressure is maintained the patient's knee is passively extended

POSITIVE TEST• At approximately 30° of flexion (0° being straight leg),

the patient complains of severe pain over the lateral femoral condyle

LEG LENGTH

Measurement of Leg Length

PROCEDURE• The patient lies in the supine position with the

legs at a right angle to a line joining the two ASISs. With a tape measure, the examiner obtains the distance from one ASIS to the lateral or medial malleolus on that side

POSITIVE TEST• (+)if difference is >1.5 cm

Functional Leg Length

PROCEDURE• The patient stands in the normal relaxed stance. The

examiner palpates the ASISs and then the (PSISs) and notes any differences. The examiner then positions the patient so that the patient's subtalar joints are in neutral while bearing weight. While the patient holds this position with the toes straight ahead and the knee straight, the examiner repalpates the ASISs and the PSISs. If the previously noted differences remain, the pelvis and sacroiliac joints should be evaluated further

POSITIVE TEST• If the previously noted differences disappear,

the examiner should suspect a functional leg length difference caused by hip, knee, ankle, or foot problems-primarily, ankle or foot problems