Special tests:
Q-Angle Test:
- Patient Position: The subject lies supine with the hips and knees extended
- Action: Draw a line connecting the Anterior Superior Iliac Spine (ASIS) to the midpoint of the Patella, and from the Tibial Tubercle to the midpoint of the Patella. Place a goniometer over the knee so that the axis is over the midpoint of the patella. Place the proximal arm over the line leading to the ASIS and the distal arm over the line leading to the Tibial Tubercle.
-Positive Finding: Q- Angle norms with the knee in extension are 13 degrees for males and 18 degrees for females. Angles greater than or less than these norms may be indicative of patellofemoral pathology.
Valgus Stress Test:
- Patient Position: 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 (laterally).
- Action: With the ankle stabilized, apply a valgus force at the knee with the proximal hand. This is done both with the knee in full extension and the between 20 to 30 degrees of flexion.
- Positive Finding: Medial knee pain and/or increased valgus movement with a diminished or absent end point as compared to the uninvolved knee is indicative of damage to primarily the MCL, PCL, and posteromedial capsule when found in full extension, and MCL when tested in 20 to 30 degrees of flexion.
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 to 30 degrees of flexion.
- Positive Finding: Lateral knee pain and/or increased varus movement with a diminished or absent end point as compared to the uninvolved knee is indicative of damage to primarily the LCL, PCL, and arcuate complex when found at full extension, and the LCL when tested at 20 to 30 degrees of knee flexion.
Lachman's Test:
- Test Positioning: The subject lies supine with the test knee flexed to 20 to 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 is indicative of a partial or complete tear of the ACL.
Anterior Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and the foot in neutral position. The examiner sits on the subjec't 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 to ensure relaxation.
- Positive Finding: Increased anterior tibial displacement as compared to the uninvolved side is indicative of a partial of or complete tear of the ACL.
Posterior Drawer Test:
- Test Positioning: The subject lies supine with the 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 Findings: Increased posterior Tibial displacement is indicative of a partial or complete PCL tear.
Posterior Sag test:
- Test Positioning: The subject lies on the 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 the 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 reflect injury to any of the following structures: PCL, ACL, POL (Posterior Oblique Ligament).
Godfrey 90/90 Test:
- Test Positioning: The subject lies supine on the table with both the hip and the knee of the involved side 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 Findings: The recognition of one Tibia resting more inferiorly than the contralateral side of may indicate a posterior sag or instability. This may be related to the PCL.
Patellar Apprehension Test:
- Test Positioning: The subject lies supine with both knees fully extended. The examiner stand opposite the involved side and places 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 the movement or contracts the quadriceps muscle to protect against subluxation, the test is indicative of a Patellar subluxation or dislocation.
Ballotable Patella Test:
- Test Positioning: The subject lies supine with both knees fully extended. The examiner stand 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 severe joint effusion.
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 "milk" or "sweep" and 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 indicative of intracapsular swelling.
Hughston's Posteromedial Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and Tibia internally rotated 20 to 30 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 a posterior force to the proximal Tibia.
- Positive Finding: Increased posterior tibial displacement, particularly of the medial tibial condyle, as compared to the uninvolved side is indicative of posteromedial rotary instability.
Hughston's Posterolateral Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and Tibia externally rotated 20 to 30 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 a posterior force to the proximal Tibia.
- Positive Finding: Increased posterior tibial displacement, particularly of the lateral tibial condyle, as compared to the uninvolved side is indicative of posterolateral rotary instability.
Hughston's Plica Test:
- Test Positioning: The subject lies supine with the involved knee fully 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 condyle. 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 asymptotic in an otherwise healthy individual. Thus, the location of the band will determine whether or not Patella tracking will be affected.
Pivot Shift Test:
- Test Positioning: The subject lies supine with the test knee in full extension. The examiner strands 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 to 30 degrees of flexion is indicative of anterolateral rotary instability second to tearing of the ACL and posterolateral capsule.
McMurray Test:
- The subject lies supine. The examiner stands with the distal hand of the grasping the subject's heel or distal leg (medially), and the proximal hand on the subject's knee with the fingers palpating in the medial and lateral joint lines.
- Action: With the knee fully flexed, externally rotate the Tibia, introduce a valgus force, and extend the knee. Repeat with the 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. Likewise, a "click" along the lateral joint line is indicative of a lateral meniscus tear.
Apley Compression Test:
- Test Positioning: 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 for stabilization and the distal hand on the subject's heel.
- Action: With the distal hand, medially and laterally rotate the Tibia while applying a downward force through the heel.
- Positive Finding: Pain, clicking, and/or restriction is indicative of either a medial or lateral meniscus tear, depending on the location of symptoms.
Apley Distraction Test:
- Test Positioning; The subject lies prone with the test knee flexed to 90 degrees. The examiner stand with the proximal hand on the subject's distal thigh for stabilization and the distal hand around the subject's ankle.
- Action: With the distal hand, distract the knee.
- Positive Finding: Relief of symptoms is indicative of either a lateral or medial meniscus tear.
Patellar Grind Test:
- 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 movement of the Patella or an inability to complete the test is indicative of Chondromalacia Patella.
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 the Tibia internally rotated 15 to 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 finger 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.
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 the Tibia externally rotated 15 to 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 finger to ensure relaxation.
- Positive Finding: Increased anterior tibial displacement, particularly of the lateral tibial condyle as compared to the uninvolved side is indicative of anteromedial rotary instability.
- Patient Position: The subject lies supine with the hips and knees extended
- Action: Draw a line connecting the Anterior Superior Iliac Spine (ASIS) to the midpoint of the Patella, and from the Tibial Tubercle to the midpoint of the Patella. Place a goniometer over the knee so that the axis is over the midpoint of the patella. Place the proximal arm over the line leading to the ASIS and the distal arm over the line leading to the Tibial Tubercle.
-Positive Finding: Q- Angle norms with the knee in extension are 13 degrees for males and 18 degrees for females. Angles greater than or less than these norms may be indicative of patellofemoral pathology.
Valgus Stress Test:
- Patient Position: 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 (laterally).
- Action: With the ankle stabilized, apply a valgus force at the knee with the proximal hand. This is done both with the knee in full extension and the between 20 to 30 degrees of flexion.
- Positive Finding: Medial knee pain and/or increased valgus movement with a diminished or absent end point as compared to the uninvolved knee is indicative of damage to primarily the MCL, PCL, and posteromedial capsule when found in full extension, and MCL when tested in 20 to 30 degrees of flexion.
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 to 30 degrees of flexion.
- Positive Finding: Lateral knee pain and/or increased varus movement with a diminished or absent end point as compared to the uninvolved knee is indicative of damage to primarily the LCL, PCL, and arcuate complex when found at full extension, and the LCL when tested at 20 to 30 degrees of knee flexion.
Lachman's Test:
- Test Positioning: The subject lies supine with the test knee flexed to 20 to 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 is indicative of a partial or complete tear of the ACL.
Anterior Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and the foot in neutral position. The examiner sits on the subjec't 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 to ensure relaxation.
- Positive Finding: Increased anterior tibial displacement as compared to the uninvolved side is indicative of a partial of or complete tear of the ACL.
Posterior Drawer Test:
- Test Positioning: The subject lies supine with the 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 Findings: Increased posterior Tibial displacement is indicative of a partial or complete PCL tear.
Posterior Sag test:
- Test Positioning: The subject lies on the 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 the 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 reflect injury to any of the following structures: PCL, ACL, POL (Posterior Oblique Ligament).
Godfrey 90/90 Test:
- Test Positioning: The subject lies supine on the table with both the hip and the knee of the involved side 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 Findings: The recognition of one Tibia resting more inferiorly than the contralateral side of may indicate a posterior sag or instability. This may be related to the PCL.
Patellar Apprehension Test:
- Test Positioning: The subject lies supine with both knees fully extended. The examiner stand opposite the involved side and places 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 the movement or contracts the quadriceps muscle to protect against subluxation, the test is indicative of a Patellar subluxation or dislocation.
Ballotable Patella Test:
- Test Positioning: The subject lies supine with both knees fully extended. The examiner stand 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 severe joint effusion.
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 "milk" or "sweep" and 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 indicative of intracapsular swelling.
Hughston's Posteromedial Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and Tibia internally rotated 20 to 30 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 a posterior force to the proximal Tibia.
- Positive Finding: Increased posterior tibial displacement, particularly of the medial tibial condyle, as compared to the uninvolved side is indicative of posteromedial rotary instability.
Hughston's Posterolateral Drawer Test:
- Test Positioning: The subject lies supine with the test hip flexed to 45 degrees, knee flexed to 90 degrees, and Tibia externally rotated 20 to 30 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 a posterior force to the proximal Tibia.
- Positive Finding: Increased posterior tibial displacement, particularly of the lateral tibial condyle, as compared to the uninvolved side is indicative of posterolateral rotary instability.
Hughston's Plica Test:
- Test Positioning: The subject lies supine with the involved knee fully 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 condyle. 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 asymptotic in an otherwise healthy individual. Thus, the location of the band will determine whether or not Patella tracking will be affected.
Pivot Shift Test:
- Test Positioning: The subject lies supine with the test knee in full extension. The examiner strands 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 to 30 degrees of flexion is indicative of anterolateral rotary instability second to tearing of the ACL and posterolateral capsule.
McMurray Test:
- The subject lies supine. The examiner stands with the distal hand of the grasping the subject's heel or distal leg (medially), and the proximal hand on the subject's knee with the fingers palpating in the medial and lateral joint lines.
- Action: With the knee fully flexed, externally rotate the Tibia, introduce a valgus force, and extend the knee. Repeat with the 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. Likewise, a "click" along the lateral joint line is indicative of a lateral meniscus tear.
Apley Compression Test:
- Test Positioning: 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 for stabilization and the distal hand on the subject's heel.
- Action: With the distal hand, medially and laterally rotate the Tibia while applying a downward force through the heel.
- Positive Finding: Pain, clicking, and/or restriction is indicative of either a medial or lateral meniscus tear, depending on the location of symptoms.
Apley Distraction Test:
- Test Positioning; The subject lies prone with the test knee flexed to 90 degrees. The examiner stand with the proximal hand on the subject's distal thigh for stabilization and the distal hand around the subject's ankle.
- Action: With the distal hand, distract the knee.
- Positive Finding: Relief of symptoms is indicative of either a lateral or medial meniscus tear.
Patellar Grind Test:
- 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 movement of the Patella or an inability to complete the test is indicative of Chondromalacia Patella.
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 the Tibia internally rotated 15 to 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 finger 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.
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 the Tibia externally rotated 15 to 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 finger to ensure relaxation.
- Positive Finding: Increased anterior tibial displacement, particularly of the lateral tibial condyle as compared to the uninvolved side is indicative of anteromedial rotary instability.
case scenario 1:
Special testing of this individual produced entirely negative results. The tests performed included: Ober's test, Anterior/Posterior Drawer, Valgus/Varus Stress, Pivot Shift, McMurray's, Apley Compression/Distraction, Clark's test and the Patellar Apprehension tests.
case scenario 2:
Despite the fact that this injury was to the quadriceps region, a quick assessment of the knee showed no significant signs of trauma. Anterior Drawer, Valgus/Varus stress, Lachman's, produced negative results.