Musculoskeletal LQ Week 10 - Knee Examination

Static and Dynamic Observation

• Symmetrical stance observation includes weight evenly distributed on both legs, assessing for deformities like genu varum or valgus, pelvic, hip, and ankle alignment, muscle mass, wasting, and balance.
• Medial compartment of the neutrally aligned knee bears 60-70% of the load.

Posture Assessment

• Posture should be assessed from anterior, lateral, and posterior views.

Anterior View

• Assess femoral torsion, genu varus/valgus, patella position, and tibial alignment.

Lateral View

• Observe for hyperextension (genu recurvatum).

Posterior View

• Check for hip leveling.

Knee Postural Alignment Anomalies - Standing

Anterior

• Genu varum (bowleg) and genu valgum (knock-knee) can be unilateral or bilateral, with newborns typically exhibiting genu varum, progressing to genu valgum before straightening around 3-4 years old.
• Assess for swelling and patella position, including tilt ("grasshopper eyes" or "squinting") and rotation ("spin").

Lateral

• Genu recurvatum (hyperextension) may indicate meniscus pathology if one knee's extension is limited compared to the other.
• Fixed flexion can indicate a contracture.
• Patella alta (high riding) increases patellofemoral contact force, potentially causing anterior knee pain.
• Camel sign indicates patella alta, with the high patella forming one hump and the infrapatellar bursa forming the second, common in females.
• Patella baja/infera (low riding) is when the inferior pole is lower.

Genu Valgus and Genu Varum

• Genu valgus presents as an L-shape at the knee.
• Genu varum has a bow shape.

Miserable Malalignment Syndrome

• Involves increased femoral anteversion, genu valgum, vastus medialis obliquus dysplasia, lateral tibial torsion, and forefoot pronation.
• These factors can create excessive lateral forces.
• Normal adult knee has approximately 6 degrees of valgus angle.

Knee Postural Alignment Anomalies - Standing

Posterior

• Similar findings to the anterior view.
• Abnormal swelling, like a popliteal cyst (Baker’s cyst), should be noted.

Knee Postural Alignment Anomalies - Sitting

Anterior

• Assess for swelling, including medial pes anserine bursitis and medial or lateral meniscal cysts.
• Observe tibial torsion (medial torsion with genu varum, lateral torsion with genu valgum).
• Have patients sit with knees flexed to 90 degrees, feet partially weight-bearing or dangling.

Lateral

• Evaluate patella position (alta is laterally displaced), baja, and bony enlargements like tibial tubercle in Osgood-Schlatter disease.

Knee Postural Alignment Anomalies - Sitting

Malalignment

• Genu valgum may correlate with pes planus, excessive subtalar pronation, lateral tibial torsion, lateral patellar subluxation, excessive hip adduction/medial rotation, and lumbar spine contralateral rotation.
• Compensatory motions for genu valgum include forefoot varus, subtalar supination, in-toeing, and ipsilateral pelvic lateral rotation.
• Genu varum may correlate with tibial varum, medial tibial torsion, ipsilateral hip lateral rotation, and excessive hip abduction.
• Compensatory motions for genu varum include forefoot valgus, excessive subtalar pronation, and ipsilateral pelvic medial rotation.
• Genu recurvatum can correlate with ankle plantar flexion and excessive anterior pelvic tilt.
• Compensatory motions for recurvatum include posterior pelvic tilt and flexed trunk posture.
• Lateral tibial torsion may correlate with out-toeing and subtalar supination.
• Compensatory motions include functional forefoot varus and subtalar pronation.
• Medial tibial torsion can correlate with in-toeing, metatarsus adductus, and subtalar pronation.
• Compensatory motions include functional forefoot valgus and subtalar supination.
• Excessive tibial retroversion correlates with genu recurvatum.
• Inadequate tibial retrotorsion correlates with a flexed knee posture.
• Inadequate tibial retroflexion correlates with altered Achilles tendon alignment and associated joint motion.
• Bowleg deformity of the tibia (tibial varum) correlates with medial tibial torsion.
• Compensatory motions for tibial varum include forefoot valgus and excessive subtalar pronation.

Dynamic Balance - Gait

• Observe gait abnormalities, including step length, stance time, and step cadence.
• Assess for abnormal tibia motion relative to the femur, indicating instability.
• Antalgic gait involves shortened stance time.
• Varus thrust can indicate Knee OA.
• Dynamic knee valgus can be seen during single or double leg squats.
• Involves excessive hip adduction and medial rotation, along with medial knee deviation and tibial abduction.
• Strengthening hip abductors can improve alignment during squats or lunges.

Functional and Gait Assessment

• Assess function first if irritability is low and neurological deficit is not expected.
• Ask patients to demonstrate movements; e.g., donning and doffing shoes, lifting from floor
• Use patient-meaningful tests and retests to aid hypothesis testing and differential diagnosis.

Functional Testing - Gait

• Assess the big picture first, then focus on region-specific details.
• Understanding normal gait is essential for observing abnormalities and determining relevance to symptoms.
• Foot and ankle functions during gait include base of support, mobile adaptation for weight acceptance, and rigid lever arm for pre-swing via subtalar joint locking and the Windlass mechanism.

Functional Testing - Gait

• Assess gait from frontal and sagittal planes, both shod and barefoot.
• Gait deviations at the ankle/foot may be secondary to specific impairments.

Functional Testing - Depending on Symptom Irritability and Ability Level

• Squat, Single Leg Stance, Single Leg Squat, Lateral Step Down

Squat

• Observe weight distribution (heels vs. mid/forefoot).
• Posterior squatting may indicate a lack of dorsiflexion.
• Assess dorsiflexion and subtalar joint movement.
• Note excessive pronation.

Single Leg (SL) Stance

• Assess the ability to perform with a narrow base of support.
• Check if the 1st MTP, 5th MTP, and calcaneus are flat.
• Observe muscle activation to maintain the medial longitudinal arch.
• Note pelvic and lumbar spine movement.

SL Squat

• Evaluates talocrural joint range of motion.
• Assesses subtalar joint usage.
• Determines hip, pelvic, and lumbar spine stability.

Lateral step down

• Assesses dynamic balance.
• Evaluates foot stability.
• Can be graded from 0-6.
• Assesses use of dorsiflexion vs. subtalar motion.
• Observe for medial tibial or knee movement.
• Evaluates pelvic stability and the need for arm support.

Functional Testing - Depending on Symptom Irritability and Ability Level

• Stairs, Hopping

Stairs

• Identify problematic aspects (ascending or descending).

Running

• Perform gait analysis if there are any problems.

Jumping and Hopping

• Evaluate movement performance and quality.
• Assess for symptoms as load increases on the lower leg, ankle, and foot.

Palpation, Range of Motion and MMT

Soft Tissue Palpation

• Biceps femoris, semitendinosus, semimembranosus, gastrocnemius, lateral collateral ligament, medial collateral ligament, quadriceps and quadriceps tendon

Posterior Knee Palpations

• Semitendinosus, semimembranosus, biceps femoris, gastrocnemius

Lateral Knee Palpation

• Lateral collateral ligament, biceps femoris

Medial Palpations

• Medial collateral ligament

Anterior Palpations

• Quadriceps muscle and tendon, patellar tendon

Bony Landmark Palpation

• Medial and lateral epicondyles and condyles of the femur, knee joint line, head of the fibula, patella.

Lateral Bony Palpation

• Lateral femoral condyle, fibular head
• Confirm fibular head position by internally and externally rotating the tibia

Medial Bony Palpation

• Medial femoral condyle

Anterior Bony Palpation

• Patella

Range of Motion

Knee flexion

Knee extension

Muscle Performance Testing

Knee flexion

Knee extension

• Grades 0-2 are gravity minimized and grades 3-5 are against gravity.

Knee Mobility

Tibiofemoral Joint

• Anterior to posterior glide of the tibia
• Posterior to anterior glide of the tibia

Anterior to Posterior and Posterior to Anterior Tibial Glide

• Knee is placed in the open packed position around 25 degrees of knee flexion.
• Thumbs are placed on anterior part of the knee, fingers wrapped around to the posterior part of the knee and the anterior or posterior glide is provided through the joint.

Superior Tibiofibular Accessory Mobility

• Assessment of the movement of the fibula on the tibia.
• Can be used as a treatment if there is stiffness.
• Flex the patients knee to 90 degrees while the patient is in supine
• Use the medial hand to stabilize the tibia and the lateral hand in a lumbrical grip to find the fibular head.
• Once ahold of the fibular head, move it anterolateral posterior medial direction to assess for stiffness.

Patellofemoral Joint

Medial patellar glides

Lateral patellar glides

Superior/inferior patellar glides

Patellar Glides

Medial and Lateral

• If you’re working with the patient in side lying and on the superior leg, you’ll be working on medial glides
• If you’re working on the leg that is closest to the table or inferior, you’ll be looking at lateral glides

Superior-inferior glide

• Patient is supine with knee in the open pack position at approx. 25 degrees of knee flexion.
• Using the web spaces of both hands, cup both the superior pole and inferior pole of the patella and working in the superior-inferior glide direction.

Special Tests

Patellofemoral Joint Special Tests

Clarke's sign

Patellar apprehension test

Clarke’s Sign

• Patient supine with knees fully extended.
• Patellar compression: provide compressive force central to the patella and assess symptoms.
• Clarke's: stabilize the superior aspect of the patella and instruct patient to contract the quadriceps muscles.

Patellar Apprehension Test

• Patient supine with knee flexed to 30 degrees.
• Apply lateral force on the medial border of the patella.

Knee Diagnoses

Patellofemoral Pain Syndrome

Patellar tilt test

Eccentric step down test

Pain with squatting

Iliotibial Band Syndrome

Noble compression test

Knee Swelling

Brush, stroke or bulge test

Patellofemoral Pain Syndrome Tests

Patellar Tilt

• Patient supine with knees extended.
• Places fingers on medial border of patella and thumbs on lateral border of patella.
• Lift patella underneath the lateral border.
• Normal is that the patella lifts about 15 degrees above horizontal
• Positive test is unable to lift lateral border of the patella above the horizontal plate.

Eccentric Step Down

• Patient stands on a step with hands on hip.
• With the uninvolved side planted on the step first, slowly lower the opposite foot down to the floor.
• Positive test is reproduction of knee pain.
• Then, with the involved side planted on the step.
• If there is no reproduction of pain, you can modify this test by having the patient tap their heel on the floor and then bring it back up.

Pain With Squatting

• Patient standing with feet hip width apart.
• Patient performs a squat.
• Positive test is reproduction of pain with the squat.

Iliotibial Band Syndrome

Noble Compression Test

• Patient supine and passively flex the hip and knee to 90 degrees.
• Palpate the lateral femoral condyle and move proximally 1-2 cm to palpate and put pressure on the distal IT band.
• While maintaining pressure on the distal IT band, move the knee from flexion into extension.

Knee Swelling

Brush, Stroke, or Bulge Test

• Supine with knee extended.
• Stroke the medial side of patient’s knee from inferior to superior direction to try and empty out effusion on the medial side of the knee, you may repeat this a few times to fully empty the medial compartment.
• Clinician provides the lateral glided stroke from superior to inferior direction, looking and assessing for any filling on the medial side of the knee.
• The interpretation is grading the stroke test (0-3).
• 0 = no fluid produced at the medial knee.
• 1 = small wave of medial fluid.
• 2 = effusion returns to the medial side.
• 3 = unable to move the effusion.

Special Test

Ligamentous Stability Special Tests

ACL

• Lachman’s
• Anterior Drawer
• Pivot-Shift

LCL

• Varus stress test

PCL

• Posterior drawer
• Posterior sag

MCL

• Valgus stress test

Meniscus

• McMurray
• Apley’s

ACL tests

Lachman’s

• Patient supine.
• Flex hip with knee flexed to 20-30 degrees.
• Stabilize anterior surface of distal femur.
• Apply an anterior translatory force through the tibia.
• Looking for excessive anterior translation and compare to other side.

Anterior Drawer

• Patient in supine hooklying; knee 60-90 degrees.
• Stabilize patient’s foot and grasp posterior knee with thumbs on anterior tibia.
• Examiner sits on patient’s foot with patient’s permission.
• Provide firm anterior pull to the knee to assess ligamentous laxity and quality of end feel.
• Compare bilaterally.

Pivot-Shift

• Patient supine with legs extended.
• Slightly flex patient’s hip, lifting leg into air and maintain knee extension.
• Stabilize patient’s ankle in clinician’s axilla.
• With both hands, grasp patient’s leg just distal to knee joint, and maximally internally rotate the tibia.
• Provide a valgus stress at knee joint.
• Maintain the valgus force on the knee while gradually bringing knee into flexion and extension.
• Repeat multiple times assessing for any clunk or shift of the knee joint.

PCL Tests

Posterior Drawer

• Patient supine with hip 45 degrees flexion and knee 90 degrees flexion.
• Stabilize lower leg and grasp patient’s tibia with the web spaces of both hands (thumbs on tibial plateau).
• Give anterior to posterior force through the tibia.
• Assess for translation and compare bilaterally.

Posterior Sag

• Patient in supine.
• Passively flex bilateral patient’s hips and knees to 90 degrees.
• Hold patient’s ankles and assess if tibial tuberosities are at the same level.

LCL Tests

Varus Sign Test

• Patient supine with limb extended over the edge of the testing table.
• The knee is extended to 0 degrees.
• The examiner applies a varus force by adducting the ankle and stabilizing the thigh.
• From medial to lateral force.
• The test is repeated at 30 degrees of knee flexion.
• Most common LCL test.

MCL Tests

Valgus Sign Test

• Patient supine with limb extended over the edge of the testing table.
• The knee is extended to 0 degrees.
• The examiner applies a valgus force by abducting the ankle and stabilizing the thigh.
• Lateral to medial force.
• The test is repeated at 30 degrees of knee flexion.

Meniscus Tests

McMurray’s

• Patient supine.
• Hold ankle in 1 hand and knee with the other.
• Lateral meniscus: middle finger on medial joint line and thumb on lateral joint line.
• Medial meniscus: thumb of lateral joint line and middle finger on medial joint line.
• Lateral Meniscus: knee is maximally flexed, internally rotated and then slowly extended.
• Medial meniscus: knee is maximally flexed, externally rotated and then slowly extended.
• Clicking, thud, locking sensation and/or reproduction of pain is a positive test.

Apley’s

• Patient prone.
• Passively flex patient’s knee to 90 degrees and add axial compression load into the tibia.
• Internally and externally rotate the tibia multiple times.
• Positive: reproduction of pain or clicking.

Functional Outcome Measures of the Lower Extremity

Berg Balance Scale

• Examines both static and dynamic balance.
• 6 static tasks.
• 8 dynamic tasks.
• Max score – 56 points predictive: scores of 45 or below = high risk for falls in elderly.
• MDC for Osteoarthritis = 4.6-3.3 points depending on initial scores, Acute stroke = 6.9 points, Chronic stroke = 4.66 points, Parkinson's disease = 5 points.
• MCID: N/A

30-Second Sit to Stand/Chair Stand Test

• Test leg strength and aerobic capacity in older adults.
• Count and record the number of times the patient achieves full stand in 30 seconds.
• A score below the average indicates an increased fall risk.
• Have patient sit on chair with arms crossed across their front.
• Instruct patient to stand and sit for 30 seconds, ensuring a full stand each time.

Timed Up-and-Go Test

• Measure of functional mobility and fall risk.
• Time and record the time it takes to stand, walk 3 meters (100 feet) and fully sit back down.
• Some age-related norms have been determined in the literature.
• Scoring: test is timed, uses 1 practice/3 trials for average score.
• Predictive: scores 11-20 typical for frail elderly; > 30 seconds = high risk for falls.

6-minute Walk Test

• Sub-maximal test for exercise endurance and aerobic capacity.
• Distance walked in 6 minutes is measured and used for comparison of changes.
• The patient is allowed to slow down, rest, or stop as needed during the test.
• The test-retest reliability has been shown effective for numerous diagnoses.

Tinetti Performance Oriented Mobility Assessment

• Multitask performance test; 16 items.
• 9 balance items: 4 static, 5 dynamic.
• 7 gait.
• Scoring occurs on a 3-pt scale, either ordinal or timed.
• MDC for Osteoarthritis = 4.2, 4 points and Stroke = 6 points.
• MCID: NA

Tennetti Scores

• Less than or equal to 18 = high fall risk.
• 19-23 = moderate fall risk.
• Greater than or equal to 24 = low fall risk.

Dynamic Gait Index

• Measure performance of multiple tasks to include: walking, speed changes, stepping over and around obstacles, climbing stairs.
• Excellent test-retest and interrater reliability.
• MDC for Community dwelling elderly = 2.9 points, Chronic stroke = 2.6 points, Stroke = 4 points, Multiple sclerosis = 4.19-5.54 points, Parkinson's Disease = 2.9 points and Vestibular = 3.2 points.
• MCID for Community dwelling elderly = 1.90
• Tests vertical head turns and horizontal head turns
• Also can be tested with stairs

Functional Gait Assessment Tool

• Measures gait ability and dynamic balance. Individuals perform 10 walking tests.

Tasks include

• Walk at steady state
• Walk and change speeds
• Walk with horizontal head turns
• Walk with vertical head turns
• Walk and pivot turn
• Walk and step over obstacles
• Walk with narrow base of support
• Walk with eyes closed
• Walk backward
• Climb stairs
• Assistive devices may be used if normally required for ambulation
• Although similar, FGA is specifically for gait and dynamic balance and does not include anything for static balance

Functional Gait Assessment Tool

• Scoring
• 0 indicates lowest level of function. Total score = 30
• MDC and MCID calculated for various diagnoses in the geriatric population
• A score of 22/30 or below may classify as a fall risk in older adults

Summary

• All these tests are used for multi-joint (hip, knee, ankle)
• It can be used as initial measure of balance, fall risk, or gait assessment
• Can use these as a tool for goals so you can test and retest to see where the patient changes and how their ability is changing with therapy

Knee Functional Testing

Hop Testing - Knee

• Single hope for distance
• Triple hop for distance
• Crossover hop for distance
• 6 meter hop for time

Hop Testing - Knee

• Single Leg and Triple Hop
• First, testing and giving results for the uninvolved side before performing on the involved side
• Always give two test runs before you actually test and measure what the result is
• A positive test or one that you can measure for the ones on the involved leg requires that the patient lands with stability
• If did not land with stability, redo the test before you can measure
• Looking for distance

Hop Testing - Knee

• 6-minute and Crossover
• Looking at time on the test
• Perform on the uninvolved side first

Balance Testing

Star excursion test

• Balance test, looking at knee stability
• Can be used for ankle stability