Knee Joint Assessment Tests and Mobilizations

Knee Joint Assessment tests and Mobilizations

1. Special Tests and Mobilization of Knee Joint Presented By: Dr. Muhammad Sohail Raza

2. Overview of Knee Anatomy: Consists of Three distinct articulations: 1) Medial Tibiofemoral Joint 2) Lateral Tibiofemoral Joint 3) Patellofemoral Joint Stabilized on either side of Collateral Ligaments: 1) Medial Collateral Ligaments 2) Lateral Collateral Ligaments 3) Anterior Cruciate Ligament 4) Posterior Cruciate Ligament 5) Oblique Popliteal Ligament 6) Arcuate Popliteal Ligament 7) Patellar Ligament ( Patellar Ligament) Menisci: 1) Medial Meniscus 2) Lateral Meniscus

3. Bursae around Knee Joint:

4. Special Test for Assessment of Knee Joint Pathologies:

5. Anterior Drawer Test Purpose: ACL Integrity Patient Position: Supine with knee flex 90◦ and foot placed on Couch. Clinician position: The patient’s foot is stabilized by sitting on the dorsum of the forefoot. Both hands grasp around the upper tibia with thumbs placed anteriorly over the joint line Action: Apply a posterior-to-anteriorly directed force through the superior tibia. Compare the involved side to the non-involved side.  Positive Test: A positive test includes the lack of an end-feel or excessive translation.

6. Posterior Drawer Test: Purpose:   To assess the integrity of the PCL . Patient Position: Supine with the hip flexed to 45° , the knee flexed to 90 ° and the foot placed on the couch. Clinician Position: The lower leg is stabilized by sitting on the dorsum of the forefoot. Both hands grasp around the upper tibia with thumbs placed anteriorly over the joint line with the thenar area of both hands positioned over the upper tibia. Action: The tibia is pushed backwards with both hands. The absence of an end-feel or excessive translation compared to the non-involved side is a positive test.

7. Valgus Stress Test: Purpose: To primarily detect pain and/or laxity of the medial collateral ligament (MCL). Patient Position: Lying supine with the leg relaxed. Clinician Position: Standing on the outside of the affected leg; the patient’s lower leg is lifted and supported between the waist and the inside of the clinician’s elbow with the knee flexed to about 20– 30 ° and the hip positioned in a degree of internal rotation and abduction . The heel of the outside hand is placed just above the lateral joint line, the inside hand is placed just below the medial joint line where the thumb can palpate the medial tibiofemoral joint line. Action: Firm inward pressure is applied with the outside hand and outward pressure with the inside hand while rotating the body away from the end of the couch to achieve a valgus stress to the knee. The test can then be repeated with the knee in full extension. Positive Test : The reproduction of medial knee pain alone is suggestive of injury to the MCL

8. Varus Stress Test: Purpose: Detect pain and/or laxity of the lateral collateral ligament (LCL) Patient Position: Lying supine towards the edge of the couch . Clinician Position: Standing on effected side in Between abducted leg and couch. The patient’s lower leg is supported between the waist and the outer elbow and the hip is positioned in some degree of internal rotation . The heel of the outside hand is placed on the upper tibia just below the lateral joint line and the inside hand is placed just above the medial joint line on the lower femur. Action: With the knee in about 20 ° of flexion and the hip internally rotated , firm pressure is applied with both hands to achieve a Varus stress while rotating the body in order to increase leverage. Positive test: Lateral knee pain or laxity on stress testing.

9. Lachman’s test : Purpose : Detect anterior (one-plane) instability and anterior cruciate ligament (ACL) laxity. Patient Position: Supine with knee 10 to 30 degree flexion. Clinician Position: The patient’s foot is stabilized between the clinician’s thigh and the couch. The outside hand is placed over the lateral aspect of the thigh just above the knee joint and the fingers wrapped around the back of the lower thigh while counter-pressure is applied anteriorly with the thumb. Action: With the outside hand stabilizing the femur, the lower hand firmly pulls the tibia forwards in an attempt to generate anterior translation. Positive Test: Increased anterior excursion of the tibia on the femur with an accompanying change in the end-feel usually indicates a significant injury

10. Pivot shift test : Purpose : To assess for anterolateral rotational instability (ALRI) and laxity of the anterior cruciate ligament (ACL). Patient Position: The patient lies supine with hip is flexed to 45° and abducted to about 30° with the knee in 50° of flexion. Clinician Position: The tibia is internally rotated by using the heel as a lever with the thumb of the caudal hand over the lateral border of the calcaneus and the fingers gripping medially . The cephalic hand is placed on the outside of the leg just below the knee joint Action: A valgus stress is applied with the cephalic hand as the knee is moved towards extension. Positive Test: The lateral tibial condyle subluxes forwards on the tibial plateau as the knee approaches extension. As a result Pain feels.

11. Reverse pivot shift test : Purpose: Assess for posterolateral rotatory instability (PLRI). Patient Position: Supine with the leg relaxed. The hip is flexed to about 45 ° and the knee taken into about 80° flexion . Clinician Position: Caudal Hand grasps the heel with forearm support medial border of foot and Cephalic Hand supports knee. Action: The caudal hand maintains the external rotation of the tibia, at the same time applying a valgus stress to the knee. The knee is then allowed to extend slowly and at around 20 – 30 ° of flexion, the iliotibial band then lies anterior to the axis of rotation, In this position, the tibia would be subluxed posterolaterally for Indication of positive test .

12. Dial test : Purpose: To assess for posterolateral rotatory instability (PLRI) Patient Position: Lying supine with the thigh abducted so that the knee can flex over the side of the couch. Clinician Position: The thigh is stabilized with the cephalic hand while the other hand grasps the heel and uses the forearm to push the foot into dorsiflexion. Action: Using the dorsiflexed foot as a lever, the knee is passively flexed to 30 ° and externally rotated. The extent of rotation is noted in comparison to the other knee but an excess of 10 ° is considered to be a positive test. T hen test is then repeated in 90 ° of flexion, still with the thigh comfortably supported on the couch

13. McMurray Test Purpose: To elicit pain and/or apprehension resulting from meniscal injury or pathology Patient Position: Supine lying Clinician Position: Towards effected limb with patient’s Hip and Knee flexed. Action: From heel of foot Tibia rotated externally. Positive test: Reproduction of the patient’s pain, click or apprehension.

14. Knee Joint Mobilizations

15. Anterior Glide: Anterior glide  is used to increase joint play and capsular stretch to encourage external rotation and extension ROM.

16. Posterior Glide The patient is positioned in supine with the knee slightly flexed and a prop placed under the distal femur. The stabilizing hand is used to prop the distal femur and the mobilizing hand is placed over the proximal tibia just below the tibial tuberosity. The mobilization itself is performed by a force perpendicular to the line of the tibia. This technique is useful for obtaining joint play necessary for knee flexion .

17. Rotational Glide: Internal and external rotation glides are useful for gaining joint play for knee flexion and extension, respectively. These glides can be performed at various points in the normal ROM of the knee with the patient positioned in supine. The stabilizing hand grasps the distal femur and the mobilizing hand grasps the heel of the patient's foot. The ankle is maximally dorsiflexed so that rotational motion is applied to the rotating tibia and not at other joints more distally. The foot is either rotated medially or laterally, depending on the mobilization preferred (internal or external rotation) and at the range where restriction may be apparent .

18. Patellofemoral Glides: Patellofemoral glides are used when restriction of the patellofemoral joint causes pain or decreased overall knee ROM/function .