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KNEE EXAMINATION STRESS TESTS
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TESTS |
POSITION OF THE KNEE |
STRUCTURES INVOLVED |
DESCRIPTION OF TEST BEING PERFORMED |
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Gravity Sign/Gravity Test |
Knees and hips flexed 90 degrees. Held by examiner. |
Posterior Cruciate and/or Posterior Oblique Ligament and/or Fibular Collateral Ligament, Popliteus Tendon, Arcuate Ligament. |
Patient lies supine with hip flexed to 45 degrees and the knee to 90 degrees. The tibia will "drop back" or sag back on the femur if the posterior cruciate is torn. Must observe both knees, because if the sag isn’t noticed, it could give you a false positive anterior drawer. |
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Posterolateral Drawer Test |
Knee flexed 90 degrees. Lower leg in neutral rotation. |
Popliteus Tendon, Fibula Collateral Ligament, Arcuate Ligament |
Patient lies supine with knee flexed 80-90 degrees, and hip to 45 degrees. Examiner medially rotates the patients foot slightly and sits on the foot to stabilize it. Examiner pushes tibia posteriorly. If tibia moves or rotates posteriorly on the medial aspect an excessive amount compared to the normal knee, the test is positive. |
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Figure 4 Palpation |
Leg flexed and crossed over the opposite knee |
Fibula Collateral Ligament |
Patient is supine with affected leg flexed and crossed with affected foot across other knee. Observe area around the medial joint line for any indentions that would reflect ligament damage. |
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Lateral Compression |
From flexion to extension |
Lateral meniscus and/or Lateral Joint internal derangement such as osteochondritis dessicans or osteochondral fractures. |
Flexing and extending the knee while apply valgus stress. Repeat with lower leg held in internal rotation and then external rotation. |
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Medial Compression |
From flexion to extension |
Medial meniscus and/or Medial joint internal derangement, such as osteochrondritis dessicans or osteochondral fracture. |
Flexing and extending the knee while applying various stress. Repeat with the lower leg held in internal rotation and then external rotation. |
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Jerk Test of Hughston |
Hip flexed 30-35 degrees, knee flexed about 80 degrees. Knee goes from flexion to full extension. |
Anterior Cruciate and/or Lateral Capsular ligaments. |
Knee is flexed to 80 degrees and the foot is internally rotated. Apply a valgus force while attempting to rotate the fibula medially as the knee is being straightened. The jerk test takes place at approximately 20 degrees of flexion. |
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Hyperextension External Rotation recurvatum |
Legs are fully extended and are held up from the toes by the examiner. |
Anterior Cruciate ligament. It may or may not involve the posterior cruciate ligament. Rotary instability may be present. Fibula Collateral Arcuate Ligament. |
The foot is raised to allow the knee to drop back into hyperextension; this is compared with the opposite side. |
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McMurray’s |
Fully flexed |
Lateral Meniscus, Medial Meniscus |
The foot is held in one hand while the other hand palpates the joint line on both sides of the knee. A click or grinding may indicate a tear of the posterior segment of the meniscus while flexing and extending the knee. |
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Apley’s Grind Test |
Flexed to 90 degrees |
Medial or lateral menisci and/or other internal derangement, such as osteochondritis dessicans or osteochondral fractures. |
Athlete is prone with knee flexed to 90 degrees. Pressure is then applied to the heel while the foot is rotated. This suggests a posterior horn injury. |
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TESTS |
POSITION OF THE KNEE |
STRUCTURES INVOLVED |
DESCRIPTION OF TEST BEING PERFORMED |
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Pivot-Shift in lateral position Slocum |
Knee fully extended and internally rotated |
Anterior Cruciate and/or Lateral Capsular Ligaments |
Athlete is lying on unaffected side with knee fully extended and internally rotated. Knee is flexed slowly and extended slowly. |
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Posterior Drawer |
Knee 90 degrees of flexion, lower leg in neutral position |
Posterior Cruciate and/or Posterior Oblique Ligament, Fibular Collateral, Popliteus Tendon, Arcuate Ligament |
Try to make sure that the knee is in a neutral position, then apply posterior pressure on the tibia and watch for excessive movement in the posterior direction without the presence of a definite end point. Sometimes it is easier to place both knees in a flexed position and watch for a posterior sag in the knee. |
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Lachman-Ritchie |
10-20 degrees of flexion |
Anterior Cruciate Ligament |
It is performed with the knee flexed approximately 10-20 degrees. With the thigh supported, the tibia is brought forward on the femur. Want to feel for excessive forward movement of the tibia on the femur. |
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Lachman |
10-20 degrees of flexion |
Posterior Cruciate Ligament |
Same technique as above except that you attempt to bring the femur forward on the tibia. As the tibia moves in a posterior direction you want to feel for a definite end point. |
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Prone Lachman |
15 degrees of flexion |
Anterior and Posterior Cruciate Ligaments |
Patient is in a prone position with involved knee flexed to approximately 15 degrees. Place one hand on anterior aspect of knee joint line with one finger on either side of knee cap at joint. Place a downward pressure on the back of the lower leg to test for anterior cruciate and opposite pressure for posterior cruciate. |
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Pivot Shift of MacIntosh |
Goes from full extension to flexion. |
Anterior Cruciate and/or Lateral Capsular Ligament |
Athlete is supine and the leg is lifted 30-45 degrees at the hip, with the knee fully extended so it falls into hyperextension. The foot and tibia are internally rotated. A valgus force is applied to the knee as it is being flexed and pressure is being applied to the head of fibula attempting to rotate it forward. |
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Valgus Stress Abduction Stress Medial Stress |
0 degrees |
Tibial Collateral Ligament, Posterior Cruciate Ligament, Posterior Oblique Ligament, Medial Capsular Ligament |
Leg is extended and examiner places one hand on inside of ankle and other hand is placed on head of fibula. A force is applied inward. Examiner stands on outside of involved leg. |
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30 degrees |
Tibial Collateral Ligament Posterior Oblique Ligament Medial Capsular Ligament |
Hand position is the same as above. The knee is flexed to 30 degrees. Want to feel for an end point. |
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Varus Stress Adduction Stress Lateral Stress |
0 degrees |
Lateral Capsular Ligaments, Fibular Collateral Ligament, Arcuate Ligament Complex, Posterior Cruciate Ligament |
Leg is extended and examiner places one hand on outside of ankle and other hand is placed on head of tibia. A force is applied toward the outside of the knee. Feel for an end point. Examiner sits to the inside of the leg involved. |
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30- degrees |
Fibular Collateral Ligament, Lateral Capsular Ligament |
Hand position is the same as above. Knee is flexed to 30 degrees. Feel for end point. |
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TESTS |
POSITION OF THE KNEE |
STRUCTURES INVOLVED |
DESCRIPTION OF TEST BEING PERFORMED |
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Anterior Drawer |
Knee flexed 90 degrees. Lower leg in neutral position. |
Anterior Cruciate Ligament ,Anterolateral Capsule Anteromedial Capsule, Tibia Collateral |
It is important to note an end point. With knee flexed to 90 degrees and foot in a neutral position, sit on foot for stability. Place both hands behind and below the knee joint with the thumbs of both hands on the joint line. Place anterior pressure on the knee to see if it will slide forward from under the femur. |
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Anterior Drawer |
Lower leg will be internally rotated 20 degrees. Knee flexed 90 degrees. |
Anterior Cruciate Ligament, Tibial Collateral Ligament, Posterior Oblique Ligament, Medial Capsular Ligament |
Technique is the same as above. The only difference is that the foot is internally rotated. Important to note an end point. |
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Anterior Drawer |
Lower leg in 20 degrees of external rotation. Knee flexed 90 degrees. |
Anterior Cruciate Ligament, Posterior Cruciate Ligament, Lateral Capsular Ligament, Fibular Collateral Ligament |
Technique is the same as above. The only difference is that the foot is externally rotated. Important to feel for an end point. |
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Resisted Extension Valgus External Rotation Test (REVERT) |
Flexed 90 degrees lower leg externally rotated |
Patellofemoral Joint |
Lower leg externally rotated maximally and knee flexed 90 degrees. Examiner applies valgus stress while patient extends knee against manual resistance. |
KNEE EXAMINATION STRESS TESTS & RESULTING INSTABILITIES
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TEST NAMES |
POSITION OF KNEE AND LEG |
STRUCTURES TESTED |
RESULTING INSTABILITY |
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Abduction Stress 30 (Valgus Stress 30)
(Medial Stress 30) |
Knee Relaxed and Flexed 30 |
Tibial Collateral Ligament, Posterior Oblique Ligament, Medial Capsular Ligaments |
Straight Medial or Anteromedial Rotary Instability |
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Abduction Stress 0 (Valgus Stress 0)
(Medial Stress 0) |
Knee Straight in Full Extension 0 |
Tibial Collateral Ligament and Posterior Cruciate Ligament, Posterior Oblique Ligament and Medial Capsular Ligaments |
Straight Medial and Straight Posterior |
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Adduction Stress 0 (Varus Stress 0)
(Lateral Stress 0) |
Knee straight in full extension 0 |
Lateral Capsular ligaments, Fibular Collateral Ligament, Arcuate Ligament Complex, Posterior Cruciate Ligament |
Straight Lateral and Straight Posterior |
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Adduction Stress 30 (Varus Stress 30)
(Lateral Stress 30) |
Knee relaxed and flexed 30 |
Lateral capsular Ligament, Fibular Collateral Ligament |
Straight Lateral or Anterolateral Rotary Instability |
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Lachman-Ritchie |
10-30 degrees of flexion, relaxed |
Anterior Cruciate Ligament |
Any instability consistent with anterior cruciate tears. If fairly isolated tear, then it will usually be Anterolateral Rotary Instability |
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Anterior Drawer |
Knee flexed 90 degrees 1. Lower Leg in Neutral
2. Lower Leg in 20 degrees External Rotation
3. Lower Leg in 20 degrees Internal Rotation |
Anterior Cruciate, Anterior Cruciate and/or Tibial Collateral, Posterior Oblique Ligament and Medial Capsular Ligaments ,Anterior Cruciate and Posterior Cruciate and possibly Lateral Capsular Ligaments and possibly Fibular Collateral Ligament |
Anteromedial Rotary or Straight Medial Instability Straight Lateral Instability |
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Posterior Drawer |
Knee Flexed 90 degrees lower leg in neutral rotation |
Posterior Cruciate and/or Posterior Oblique Ligament and/or Fibular Collateral Ligament Popliteus Tendon, Arcuate Ligament |
Straight Posterior Instability |
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Gravity Sign/Gravity Test |
Knee and Hips Flexed 90 degrees held by examiner |
Posterior Cruciate and/or Posterior Oblique Ligament and/or Fibular Collateral Ligament, Popliteus Tendon, Arcuate Ligament |
Straight Posterior Instability |
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Posterolateral Drawer |
Knee Flexed 90 degrees Lower Leg in Neutral Rotation |
Popliteus Tendon, Fibular Collateral and Arcuate Ligament |
Posterolateral Rotary Instability |
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External Rotation Recurvatum (Hyperextension Test) |
Knees Extended and Legs held up from the toes by the examiner |
Popliteus Tendon, Fibular Collateral and Arcuate Ligament |
Posterolateral Rotary Instability |
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TEST NAMES |
POSITION OF KNEE AND LEG |
STRUCTURES TESTED |
RESULTING INSTABILITY |
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Pivot-Shift (McIntosh) |
Hip flexed 30 to 45 degrees, Knee fully extended, Foot and Tibia internally rotated, while knee goes from full extension to flexion |
Anterior Cruciate and/or Lateral Capsular Ligaments |
Anterolateral Rotary Instability |
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Jerk Test (Hughston) |
Hip flexed 30-45 degrees knee flexed about 80 degrees, foot and tibia internally rotated, while knee goes from flexion to full extension |
Anterior Cruciate and/or Lateral Capsular Ligaments |
Anterolateral Rotary Instability |
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Pivot-Shift in lateral position (Slocum) |
Athlete lying on unaffected side, knee fully extended and internally rotated, knee is flexed slowly and extended slowly |
Anterior Cruciate and/or Lateral Capsular Ligaments |
Anterolateral Rotary Instability |
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Figure 4 Palpation |
Patient is supine with affected leg flexed and crossed with affected foot across other knee |
Fibular Collateral Ligament |
Straight Lateral Instability Anterolateral Rotary and/or Posterolateral Rotary Instability |
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McMurray |
Flexing and extending Knee fully while holding the lower leg in internal rotation and external rotation and reversing throughout the range of motion |
Lateral Meniscus and/or Medial Meniscus |
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Lateral Compression Test |
Flexing and extending the knee while applying Valgus stress. Repeat with lower leg held in internal rotation and then external rotation. |
Lateral Meniscus and/or Lateral Joint Internal Derangement such as osteochondritis dessicans or osteochondral fractures |
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Medial Compression Test |
Flexing and extending the knee while applying Varus stress. Repeat with lower leg held in internal rotation and then external rotation. |
Medial Meniscus and/or Medial Joint Internal Derangement such as osteochondritis dessicans or osteochondral fractures |
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Apley’s Grind Test |
Patient prone, force applied from foot distal to proximally while knee is flexed 90 degrees and lower leg is switched from internal rotation to external rotation and back |
Medial Meniscus and/or Lateral Meniscus and/or other internal derangement such as osteochondritis dessicans or osteochondral fractures |
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