Knee anatomy and clinical tests 2024.pdf

This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.

1. KNEE
ANATOMY & CLINICAL TESTS
Dr Vimal Prakash
MBBS,MS,DNB
AIIMS Jodhpur

2. KNEE JOINT
•Tibiofemoral joint – modified
hinge joint
•Patellofemoral joint – saddle joint
•Articular (hyaline) cartilage covers
femoral condyles, tibial plateaus,
trochlear groove, and patellar
facets

3. Major stabilisers of tibiofemoral joint
Static stabiilisers Dynamic stabilisers
Tibiofemoral ligaments Qudriceps
Medial and lateral meniscusHamstrings
Topography of articular surfaceGastrocnemius
Loads across articular surfacepopliteus

4. •PATELLA
•PROXIMAL TIBIA
•DISTAL FEMUR
OSSEOUS STRUCTURES
EXTRA ARTICULAR
TENDINOUS STRUCTURES
•MEDIAL STRUCTURES
•LATERAL STRUCTURES
•POSTEROMEDIAL CORNER
EXTRAARTICULAR
LIGAMENTS
•MEDIAL AND LATERAL MENISCUS
•ACL AND PCL
INTRAARTICULAR
STRUCTURES

5. OSSEOUS STRUCTURE
•DISTAL FEMUR
•Medial ,lateral condyles
•Rounded posteriorly , flat anteriorly
•Groove between condyles
Anteriorly - patellofemoral groove/trochlea
Posteriorly - Intercondylar notch

6. •Medial condyle articular articular surface is longer
•Lateral wider
•Axis
Medial condyle – sagittal plane
Lateral condyle – 22 degree angle to sagittal plane
•Epicondyles – origin of collateral ligaments

7. PROXIMAL TIBIA
•Two flat surfaces – Condyles which
articulate with femoral condyles
•intercondylar eminence with medial
and lateral tubercles
•Posteroinferior slope 10 - 15°
•Medial tibial plateau – Oval shaped,
concave
•Lateral tibial plateau – round
shaped, convex

9. PATELLA
❖Largest sesamoid bone
❖Thickest articular cartilage (5mm)
❖Triangular
❖Smaller medial , larger lateral facet
❖extension – distal part of lateral facet articulate with lateral femoral
condyle
❖flexion – contact moves proximally ,
❖complete flexion - proximal portions of both condyles touch femur

10. Blood supply
anastomoses of:
•five genicular branches of popliteal artery
•medial and lateral superior genicular arteries
•medial and lateral inferior genicular arteries
•middle genicular artery
•descending branch of lateral circumflex femoral artery
•descending genicular branch of femoral artery
•circumflex fibular branches of posterior tibial artery
•anterior and posterior recurrent branches of anterior tibial
artery

11. Nerve supply
Articular branches from
•Femoral anteriorly
•Tibial nerve posteriorly
•Common fibular laterally
•Obturator and saphenous medially

12. Nerves in relation
•Tibial (L4-S3)
• CPN (L4-S2)
•Deep peroneal
•Superficial
peroneal
•Sural
•Saphenous
(L2-4)

13. Capsule
•surrounds all three articulations
•extends proximally into the
suprapatellar pouch.
•synovial lining also covers the cruciate
ligaments (making them intraarticular
but extrasynovial)

14. Bursae around knee
•suprapatellar
•prepatellar
•subcutaneous infrapatellar
•deep infrapatellar
•posterior (between muscle and bone)
•popliteal
•gastrocnemius
•semimembranosus

15. EXTRAARTICULAR TENDINOUS STRUCTURES
QUADRICEPS MECHANISM
HAMSTRINGS GROUP
GASTROCNEMIUS
POPLITEUS
ILIOTIBIAL BAND

16. QUADRICEPS MECHANISM
QUADRICEPS TENDON
•RECTUS FEMORIS TENDON – ANTERIOR LAYER
•VASTUS INTERMEDIUS – DEEPEST LAYERVASTUS
MEDIALIS AND LATERALIS – MIDDLE LAYER
PATELLAR TENDON –APEX OF DISTAL
POLE OF PATELLA TO TIBIAL TUBEROSITY

17. •Patellofemoral ligaments Medial (MPFL), lateral (LPFL
•Femoral epicondyles to medial
Patellofemoral ligaments - Medial (MPFL),
lateral (LPFL)
•Femoral epicondyles to medial/lateral patella
•stabilizers of patella
Medial retinaculum
•aponeurosis of vastus medialis –-insert to side of
patella
•prevent lateral displacement of patella in flexion
Lateral retinaculum
•extension of vastus lateralis
•attach to ITB
•/lateral patella
•Primary stabilizers of patella (esp.

18. Structures on lateral aspect
•Iliotibial tract
•Biceps femoris
Superficial
•Lateral
patellofemor
al ligament
•Lateral
patellar
retinaculum
Middle

19. •LCL
•Fabellofibular
ligament
•Popliteus
•Popliteofibular
ligament
•Capsule
•Arcuate
ligament
DEEP

20. Medial structures
•sartorius
•Fascia
Superficial
•Superficial MCL
•Posterior oblique
ligament
•Medial
patellofemoral
ligament
•Medial patellar
retinaculum
•Semimembranosus
•Pes anserinus
Middle

21. •Deep MCL
•Meniscofemoral fibres
•Meniscotibial fibres
•capsuleDeep

22. POPLITEUS
•Insertion: tibia proximal to soleal line below tibial condyles
•Medial rotator of tibia - initial stages of flexion
•Withdraw lateral meniscus in flexion
•Rotary stability to femur on tibia
•prevent forward dislocation of femur on tibia

•Lateral femoral condyle
•Fibula (popliteofibular ligament)
•Posterior horn of lateral meniscus3 origins

23. MEDIAL COLLATERAL LIGAMENT
❑Superficial MCL
•superficial to medial capsule, capsular ligaments
•Origin: medial epicondyle
•Insertion: 7-10 cm below joint line on posterior
half of medial tibial metaphysis deep to pes
anserinus .
•Length – 8 to 10 cm

•primary stabilizers of medial knee against valgus
and external rotary stress

24. ❑Deep MCL
•Origin: femoral condyle and epicondyle
•Insertion: just below tibial articular margin.
•meniscofemoral portion : meniscal attachment to
femoral origin. longer and stronger
•meniscotibial portion: extend as coronary ligament
of meniscus tibial insertion.
•resists valgus and rotary stresses

25. ❑Posteromedial corner
•overlapping ligaments, capsular thickenings and
tendons in posteromedial aspect of knee
• contribute to knee stability
❖5 components
1- posterior oblique ligament (POL)
2- semimembranosus tendon and expansions
3- OPL
4- posteromedial joint capsule
5- posterior horn of the medial meniscus
•Injury cause valgus and rotatory laxitiy, increased
forces on cruciate ligaments or persistent pain

26. Posterior oblique ligament
•Thickening of the medial capsule
•Proximal insertion : adductor tubercle
•Distal insertion : three arms:
(1) central/tibial arm – edge of posterior
surface of tibia close to articular margin
(2) superior/capsular arm - continuous with
posterior capsule and proximal part of OPL
(3) inferior/distal arm - attaches to SM tendon
sheath and tibia just distal to insertion of SM
tendon

27. Oblique popliteal ligament(OPL)
•Broad fascial band
•Origin: capsular arm of POL and lateral
expansion of semimembranosus
•cross posterior aspect of knee towards lateral
femoral condyle.
•Insertion: meniscofemoral portion of posterior
capsule and fabella

28. SEMIMEMBRANOSUS
•Action: Flexion of knee, internal rotation of tibia
Tenses posterior capsule & posteromedial structures
•5 distal expansions
1)Oblique popliteal ligament – tightens posterior capsule
2)To posterior capsule, posterior horn of medial meniscus
3)Towards superficial MCL
4)direct head to tubercle on posterior aspect of medial
tibial condyle
5)distal portion - fibrous expansion over popliteus and fuse
with periosteum

29. LATERAL COLLATERAL LIGAMENT(LCL)
•Proximal insertion: proximal (1.4 mm) and
posterior (3.1 mm) to lateral epicondyle
•Distally : 8 mm posterior to anterior aspect of
fibular head, 28 mm antero-inferior to
proximal tip of fibular styloid
•Action: primary static stabilizer to varus stress
in extension to 30 degree flexion.
•resistance to external rotation of tibia
•Length: 70 mm

30. ANTEROLATERAL LIGAMENT(ALL)
•femoral insertion : posterior and proximal to
the insertion of LCL
•tibial insertion: between Gerdy’s tubercle (18
to 25 mm posterior) and fibular head
•extraarticular structure
•Function: anterolateral stability, prevent
proximal-lateral tibia from subluxation
•stabilizing force most significant at 30 and 90
degrees flexion.

31. INTRAARTICULAR STRUCTURES
•Anterior cruciate ligament
•Posterior cruciate ligament
•Medial and Lateral meniscus

32. Meniscus
•Medial and lateral meniscus
•crescents, triangular in cross section
•dense, tightly woven collagen fibers
•Type of fiber arrangement
Circumferential, radial and perforating fibers
•Periphery - convex, fixed ,attached to capsule, except
where popliteus interposed
•attached to tibial plateau by coronary ligaments

33. •Vascular supply : lateral and medial
geniculate vessels (inferior and superior).
•through the vascular synovial covering of
the anterior and posterior horn attachments
•Branches from vessels perimeniscal
capillary plexus
•circumferential pattern with radial branches
toward the center

34. Vascular zones of meniscus
•Red zone – good blood supply
10% to 30% of the width in
medial meniscus and 10% to
25% in lateral meniscus.
•Red white zone- minimal blood
supply
•White zone- No blood supply
receives nutrition through
diffusion

35. Functions of menisci
•joint filler, compensate incongruity between
femoral and tibial articulating surfaces
•prevent capsular/ synovial impingement in
movements.
• joint lubrication, distribute synovial fluid
throughout joint .
•rotary stabilizers
•smooth transition from pure hinge to gliding
or rotary motion in flexion to extension
•Increase contact area x 2.5

36. •reduces contact stress between the bones.
•prevent mechanical damage to articular cartilage
•Shock absorbing
•uniform load-transmitting forces
•medial meniscus - posterior wedge to resist
anterior translation of the tibia on the femur

37. Medial meniscus
•C shaped structure
•Anterior attachment: tibia anterior to the
intercondylar eminence and to ACL
•posterior horn : in front of PCL attachment,
posterior to intercondylar eminence.
•Periphery attached to medial capsule and
upper border of the tibia (coronary ligaments)

38. Lateral meniscus
•circular
•anterior horn attachment: tibia medially in front of
intercondylar eminence
•posterior horn attachments :
✔posterior to intercondylar eminence, in front of medial
meniscus attachment in tibia
✔to femur by ligament of Wrisberg and Humphry
✔fascia covering popliteus muscle
✔arcuate complex at posterolateral corner

39. •Attached to both cruciate ligaments
•separated from the LCL by the popliteal tendon
•flexion and extension -menisci move with tibial condyles
•rotation – anterior, posterior attachments follow tibia,
intervening part follows femur.
•Rotation- lateral meniscus having less chance of injury - Attached
to popliteus muscle and ligament of Wrisberg/Humphry, follows
the lateral femoral condyle
•IR + flexion - the popliteus muscle draws lateral meniscus
prevent from being caught between femur and plateau of tibia

40. Types of meniscal tear
•(1) longitudinal tears
•(2) radial and oblique tears
•(3) horizontal cleavage tears
•(4) complex tears (combination
of longitudinal and cleavage tears
•(5) tears associated with cystic
menisci
•(6) tears associated with discoid
meniscus

41. Anterior cruciate ligament(ACL)
•longitudinal bundles of collagen
•intracapsular, extrasynovial.
•anteromedial (AMB) and posterolateral bundle
(PLB) named for insertion site on the tibia.
•Length 31 to 35 mm and 31.3 mm2 in cross
section.
•tibial ACL insertion 10 x 14 mm
•femoral insertion 8 x15 mm

42. •femoral insertion - AMB inserts
proximally and anteriorly. PLB inserts
distal and posterior.
•Anterior border of femoral insertions of
AMB and PLB - lateral intercondylar
ridge(resident’s ridge)
• bifurcate ridge separates AMB and PLB
insertion
•Tibial insertion – anteromedial aspect
of intercondylar area on tibia.tibial
footprint overlap anterior root of
lateral meniscus footprint

43. •blood supply - middle geniculate artery,
•Additional supply - retropatellar fat pad (inferior medial and
lateral geniculate arteries). plays more role when ligament is
injured.
•osseous attachments of ACL contribute little to its
vascularity.
•Nerve supply - posterior articular nerve, branch of tibial
nerve
•Mechanoreceptors on surface.mostly at bony insertions.

44. •Action : restraint to anterior tibial
displacement (85% of the resistance to the
anterior drawer test at 90 degrees flexion
and neutral rotation.
•AMB tight in flexion
•PLB tight in extension(principal resistance
to hyperextension)
•Tension least at 30 to 40 degrees flexion.
•secondary restraint to tibial rotation and
varus-valgus angulation in full extension
•proprioceptive function
(mechanoreceptors)

45. Posterior cruciate ligament
•Two parts - large anterolateral bundle (ALB), smaller
posteromedial bundle (PMB)
•runs obliquely to back of the tibia.
•intrasynovial extraarticular
•proximally - lateral surface of the medial condyle
•larger and stronger than the ACL.

46. •femoral insertion - ALB - 7.4 mm from trochlear
point, 11.0 mm from the medial arch point, 7.9 mm
from the distal articular cartilage.
•tibial insertion - 6.1 mm from posterior medial
meniscus root, 4.9 mm from bundle ridge, 10.7 mm
from “champagne glass” drop-off
•bundle ridge - horizontal bony prominence separate
ALB and PMB.

47. •ALB tight in flexion, PMB tight in extension
•recent studies shows synergistic action
•rotation of knee occurs around axis of PCL
•guide the “screw-home” mechanism on
internal rotation of femur in terminal
extension.
•resistance to posterior translation of tibia
on femur
•check of hyperextension once ACL
ruptured.
•restrains external, internal, and
varus-valgus rotation.

48. Axis around knee

49. BIOMECHANICS OF KNEE JOINT
Biomechanical functions of knee joint are:
•Locomotion with:
– As little energy requirements from the muscles as possible
– Stability while performing activity on different terrains.
• To transmit, absorb and redistribute forces caused during the
activities of daily life:
– Support during weight-bearing
– Mobility during non-weight bearing

50. •THREE ROTATIONS:,THREE TRANSLATIONS:
• Rotations:
– Flexion-extension: Up to 160° of flexion (from 5° of
hyperextension)
– Varus-valgus: 6–8° in extension
– Internal-external rotation: 25–30° in 90° of flexion
•Translation:
– Anteroposterior: 5–10 mm
– Compression: 2–5 mm
– Mediolateral: 1–2 mm

51. •Medial condyle is longer than lateral
•Lateral condyle is larger
•Instantaneous center of rotation
center of rotation for different rotations
are different due to different radii of
curvature of the femoral condyles and
coupled gliding movement

52. Roll-back mechanism
•Indigenous way of increasing flexion
•4 bar link mechanism by two cruciate
ligaments
•Posterior translation of instantaneous
centre of rotation of knee with flexion
•Increase flexion
•Prevent soft tissue impingement posteriorly
•Decrease patellar load
In flexion
•Rolling – first 10 -25 degree
•Gliding – with further flexion

53. Screw-lock mechanism
•“homing action” of tibia in last
15° of extension. The tibia has to
“home” itself on the femur by a
screwing action of external
rotation at the end of knee
extension, so it externally
rotates 5° in the last 15° of
extension

54. •Medial plateau longer than lateral -> more movement to happen at
medial plateau for same extension -> due to continued movement at
medial plateau, tibia rotates externally (if foot free) or femur rotate
internally ( foot olanted)
•Posterolateral bundle ACL act as pivot
•Advanteges – stability to knee in extension , prevent buckling ,
relaxes quadriceps in standing
•Unlocking
•Initiated by popliteus
•In first 0-20 flexion, tibia does IR

55. CLINICAL TESTS
TESTS FOR MENISCUSLIGAMENT STRESS TEST ROTARY TESTS
Mcmurrays test Valgus stress testSlocum Anterior Rotary Drawer Test
Apleys grinding testVarus stress testJerk Test of Hughston and Losee
Squat test Anterior drawer testLateral Pivot Shift Test of Macintosh
Thessaly test Lachman testFlexion-Rotation Drawer Test
Joint line tendernessPosterior drawer testExternal Rotation-Recurvatum Test
Quadriceps active testReverse Pivot Shift Sign of Jakob,
Hassler, and Stäubli
Tibial External Rotation (Dial) Test
Posterolateral Drawer Test

56. McMurray test
•Test for meniscal injury
•patient supine, knee acutely and forcibly flexed,
•medial meniscus -palpate posteromedial margin
of the joint with one hand while grasping the foot
with the other hand.
•Keep knee completely flexed, leg externally
rotated with valgus stress , knee slowly
extended.
•lateral meniscus - palpate posterolateral margin,
internally rotate the leg as far as possible, slowly
extend knee, with varus stress, feel for a click.

57. •Mechanism - femur passes over tear in meniscus, a
click heard or felt.
•Posterior peripheral tear of meniscus - click
produced between complete flexion and 90
degrees.
•Popping with greater degrees of extension - tear of
middle and anterior part.
•Sensitivity 70% specificity 71%

58. Apleys grinding test
•patient prone
•knee flexed to 90 degrees, anterior thigh fixed
against table.
•foot and leg then pulled upward to distract the
joint and rotated to place rotational strain on
the ligaments
•Distraction test painful + increased rotation on
one direction – ligamentous injury.
•foot and leg pressed downward,rotated as joint
is slowly flexed and extended
•On compression - pain at joint line + restricted
movement towards that side rotation –
meniscal injury
•Sensitivity 60% specificity 70%

59. Squat test
•several repetitions of afull squat with
the feet and legs alternately internally
and externally rotated .
• Pain on the medial or lateral side of
the knee - side of torn meniscus.
• Pain in internally rotated position -
injury to the lateral meniscus
•pain in the external rotation- injury to
the medial meniscus.
•localization of the pain is more
dependable than position of rotation

60. Thessaly test
•stand flatfooted on the floor on affected
leg.
•Examiner support the patient
•patient rotate knee and body, internally
and externally, three times with knee in
20 ° flexion.
•medial or lateral joint - line
discomfort/sense of locking/catching.

61. •joint line tenderness is the best “common” test, sensitivity 63% and
specificity 77%.
•McMurray, 70% and 71%
• Apley test, 60% and 70%
• Combined testing will improve the accuracy

62. Abduction (Valgus) Stress Test
•supine on table
•normal limb examined first
•limb abducted off side of the table, and the
knee to 30 degrees .
•one hand on lateral aspect of knee, with
other hand hold ankle.
• Gentle abduction or valgus stress to knee +
external rotation on ankle.
•Repeated to the point of producing mild pain
•Pain/opening indicate MCL injury

63. •repeat valgus stress in full extension with
gentle swinging motion.
•Don’t forcibly abduct.
•Alternative - patient’s ankle placed in the
examiner’s axilla. one hand used to palpate
medial ligaments ,joint line to assess degree of
instability.
•Opening on valgus stress at full extension -
concomitant injury to POL and either ACL or
PCL

64. Adduction (Varus) Stress Test
•Normal limb first
•hand to medial side of the knee and apply
adduction force .
• knee in full extension and 30° flexion.
•Alternate - hip abducted externally rotated
and knee flexed, heel placed on opposite
knee in a figure 4 position
• lateral aspect knee palpated for taut,
narrow band consisting of LCL.
•If LCL is torn,band not prominent

65. •In extension, intact cruciate ligaments and posterior capsule are taut -
only little abduction/adduction instability is detectable.
•In flexion, relaxes the posterior capsule- greater degree of instability.
•Abduction or adduction stress positive extension- cruciate ligament
disruption in addition to collateral ligament disruption

66. Anterior Drawer Test
•Patient supine
•hip in 45° flexion, knee in 90°, foot placed on table.
•Sit on dorsum of foot
•place both hands behind knee to feel for relaxation
of hamstring.
• Proximal leg gently and repeatedly pulled and
pushed anteriorly and posteriorly
•Note movement of the tibia on the femur.
•done in three positions of rotation
•neutral rotation,30° ER ,30° IR.

67. •30° IR tighten PCL - obliterate an otherwise positive
anterior drawer test
•Anterior drawer sign 6 to 8 mm greater than opposite
knee - torn ACL.
•Make sure tibia is not sagging posteriorly before test.
•In such knees, watch for displacement of tibia from
neutral starting point.
•Relationship of anterior medial femoral condyle to
the anterior medial tibia should be noted.
•Normal medial tibia extend 5 to 10 mm anterior to
medial femoral condyle.

68. • Small degrees of anterior translation of the tibia on the femur detected extended
position,where “doorstop” effect of the posterior horn of the menisci is absent

69. Lachman Test
•Useful in swollen and painful knee.
•preferred test for ACL .
•Patient supine
•Limb in slight external rotation with knee 15 -
20° flexion
•femur stabilized with one hand, firm pressure
applied to the posterior aspect of proximal
tibia, lifted forward to translate it anteriorly.
•thumb on anteromedial joint margin.
•anterior translation of the tibia palpated by
thumb.

70. •Anterior translation with soft end point - positive test
•hamstrings must be relaxed
Grade 1 - 1 to 5 mm
Grade 2 - 6 to 10 mm,
Grade 3 > 10 mm of anterior displacement compared to
opposite
•subclassification
Add “A” for a firm or hard endpoint
“B” for soft endpoint.
•Silhoutte of inferior pole of patella, patellar tendon, and
proximal tibia shows slight concavity - anterior translation
obliterates the patellar tendon slope

71. Posterior Drawer Test
•patient supine
•knee flexed to 90 degrees
•Both knees placed in position
•foot secured to the table by sitting on it.
•thumb is placed on each anteromedial joint line .
•Posterior force is applied on the proximal tibia, opposite of
anterior drawer test.
•Posterior movement of the tibia on the femur .
•Compare with neutral position.

72. Abnormal rotation of tibial condyles also noted
•With posterolateral instability, tibia rotates
posteriorly and laterally around axis in intact
posterior cruciate ligament.
•combined posterior cruciate and posterolateral
instability, tibia subluxate posteriorly and knee
joint shows increase in posterolateral subluxation.

73. • Loss of the normal 1-cm anterior stepoff in medial tibial plateau with
respect to the medial femoral condyle - torn PCL.
•hips positioned 90 degrees in the supine position, knees flexed to 90
degrees, heels supported in examiner’s hands.
•tibia sags visibly posteriorly in posterior instability
• This test also should be done with the patient prone and the knee
flexed to 90 degrees- Check for posterior drawer sign and rotation of
foot

74. •Both knees placed position for a posterior drawer test
•Normal anterior aspect of the tibia has 10-mm anterior stepoff in
relation to the anterior aspect of medial femoral condyle.
•A posterior drop back with decreased prominence of the tibial margin
compared with the opposite knee indicates injury to the PCL.

75. Quadriceps Active Test
•Supine, relaxed limb supported, knee flexed to 90
degrees in drawer test position.
•Adequate support of the thigh
•Make a gentle quadriceps contraction(active)
•Contraction of the quadriceps muscle -anterior shift
of the tibia of 2 mm or more – PCL injury

76. Slocum Anterior Rotary Drawer Test
•Position of drawer test
•degree of anterior displacement in 15 degrees of IR, 30
degree ER , and neutral rotation
• positive anterior drawer in neutral tibial rotation that is
accentuated in 30 degrees of external tibial rotation and
reduced in 15 degrees of internal rotation indicates
anteromedial rotary instability.
•opposite indicates anterolateral rotary instability.

77. Jerk Test of Hughston and Losee
•Patient supine, limb supported, knee flexed to 90° ,
tibia rotated internally.
•For right knee - foot grasped with right hand and
tibia internally rotated , valgus stress with left
hand over the proximal tibia
•knee extended gradually, maintain internal
rotation and valgus stress .
•lateral tibia subluxes forward with sudden jerk at
30° flexion – Test positive

78. Lateral Pivot Shift Test of Macintosh
•knee extended, foot lifted, leg internally rotated,
and valgus stress to lateral side of leg around
fibular neck
•With the knee extended and internally rotated,
tibia subluxed anteriorly.
•knee flexed slowly, valgus and internal rotation
maintained.
•As knee flexed past ~ 30 degrees, ITB passes
posterior to the center of rotation of the knee ,
reduces lateral tibial plateau on lateral femoral
condyle.

79. •isolated tear of the ACL produces minor subluxation
•+ lateral capsular complex or/and semimembranosus corner injury -
greater subluxation
•Cant elicit in Severe valgus instability/MCL injury because of lack of
medial support.
•Pivot shift tested when knee moved from extension to flexion, jerk
test is elicited in flexion to extension.

80. Alternate slocum’s method
•lateral decubitus position with the
affected side up
• pelvis 30 degrees posteriorly, medial
side of the foot on examining table,
knee in full extension.
•This position eliminates rotational
effects of hip, allows knee to fall to
valgus position, internally rotates
tibia on the femur.

81. •thumbs placed on femoral and tibial aspect of joint posteriorly
•index finger placed across joint anteriorly.
•knee pressed gently forward to flexion.
•result is positive if reduction occurs as the knee passes the 25- to
45-degree range of flexion
• smooth or sudden palpable / audible repositioning.
•Advantage - lesser degrees instability detected, less painful

82. Flexion-Rotation Drawer Test by Noyes
•Tests ACL function in two planes, the
anteroposterior and femoral rotation
•Combines features of Lachman test and Hughston
pivot shift test
•patient supine,knee at 0 degrees (not
hyperextended)
•leg lifted upward, femur allowed to fall back and to
rotate externally. This cause anterolateral tibial
subluxation as the starting position .
•While knee flexed,tibia moves backward and femur
rotates internally- joint reduced - test is positive.

83. External Rotation-Recurvatum Test
•Detect abnormal external rotation of tibia on
femur associated with or in combination with
excessive recurvatum.
•patient supine, result compared with the
normal knee.
•Move from 10° flexion to maximal extension
while external rotation of the proximal end
of the tibia and amount of recurvatum
observed and palpated.
•positive if excessive rotation and recurvatum
with apparent varus deformity occur.
•positive test - PCL, posterolateral corner, and
LCL are torn.

84. Reverse Pivot Shift Sign of Jakob, Hassler,
and Stäubli
•lateral tibial plateau shifts from a
position of posterior subluxation to a
position of reduction as the flexed
knee is extended under valgus stress
and foot in external rotation.
•plateau subluxates again as the knee is
flexed in the opposite manner.
• discomfort / feeling of giving way
•positive test - PCL, arcuate complex,
and LCL are all torn

85. Tibial External Rotation (Dial) Test
•When an injured knee tested for posterolateral
instability, external rotation of tibia measured at 30 and
90 degrees of knee flexion.
•supine or prone.
•foot externally rotated with force.
•External rotation measured by foot–thigh angle
•tibial plateaus palpated to determine relative positions
compared with femoral condyles.
•This determines whether the external rotation is caused
by the lateral tibial plateau moving posteriorly
(posterolateral instability) or by the medial plateau
moving anteriorly (anteromedial instability).

86. •>10° difference in ER pathologic.
•> 10° increase in external rotation compared
with that of the contralateral side at 30° flexion,
but not at 90 degrees - isolated injury to the
posterolateral corner.
•If pathologic external rotation exists at 30
degrees of knee flexion and increases in 90
degrees - injury to PCL + PLC
•not reliable in the presence of medial
instability.

87. Posterolateral Drawer Test
•supine
•hip flexed 45 degree,knee flexed 90
degree, tibia in 15 degree ER
• foot fixed,posterior drawer test done.
•posterolateral instability if lateral tibial
condyle externally rotates.
•grossly positive result - injury to PCL
and PLC

88. THANK YOU