Special Tests

Page address: http://ahn.mnsu.edu/athletictraining/spata/kneemodule/specialtests.html/

Brush/Sweep/Wipe Test

Steps: Patient is supine with his/her legs extended & relaxed; Examiner uses one hand just below the joint line on the medial side & strokes proximally toward the patient's hip 2–3 times; Examiner uses the other hand to stroke down the lateral side of the patella; Examiner observes for a fluid wave bulge just below the medial distal portion or patellar border
Positive Test: Fluid wave bulge just below the medial distal portion or patellar border
Positive Test Implications: Intracapsular effusion/swelling
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Ballotable Patella Test

Steps: Patient lies supine while the examiner "milks" the knee capsule; Examiner ends by placeing proximal hand over the suprapatellar pouch and the distal hand (mainly the thumb and index finger of the distal hand) over the patella; Examiner compresses the suprapatellar pouch with the proximal hand and then compresses the patella into the femur
Positive Test: Patella moves downwardly and then rebounds once the pressure on the patella is removed; appearance of a floating or ballotable patella
Positive Test Implications: Indicative of moderate to severe effusion (depending on the amount of movement compared bilaterally)
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NOTE: If a ballotable patella is present, the examiner should take joint line, proximal and distal girth measurements.

False positive – prepatellar bursitis may present with swelling in the same general area, however, the test is negative if the patella does not depress & rebound with pressure.

Valgus Stress Test (full extension)

Steps: Patient is supine with the involved leg close to the edge of the table and the knee in full extension; Examiner supports the medial portion of the distal tibia with one hand while the other hand grasps the knee along the lateral joint line; Examiner applies a medial (valgus) force to the knee & the distal tibia is moved laterally while the knee is in complete extension
Positive Test: Increased laxity, pain, and guarding
Positive Test Implications: Injury to the MCL, medial joint capsule; probable ACL/PCL involvement if there is no endpoint
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Valgus Stress Test (25–30 degrees of flexion)

Steps: Patient is supine with the involved leg close to the edge of the table and the knee is flexed ~ 25–30 degrees; Examiner supports the medial portion of the distal tibia with one hand while the other hand grasps the knee along the lateral joint line; Examiner applies a medial (valgus) force to the knee & the distal tibia is moved laterally while the knee is in 25–30 degrees of flexion
Positive Test: Increased laxity, pain, guarding
Positive Test Implications: Injury to the MCL; No end point indicates a Grade 3 injury; solid end point with no laxity but pain indicates a Grade 1 injury
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Varus Stress Test (full extension)

Steps: Patient is supine with the involved leg close to the edge of the table and the knee is in full extension; Examiner supports the lateral portion of the distal tibia with one hand while the other hand grasps the knee along the medial joint line; Examiner applies a lateral (varus) force to the knee & the distal tibia is moved medially while the knee is in complete extension
Positive Test: Increased laxity, pain, and guarding
Positive Test Implications: Injury to the LCL, lateral joint capsule, & arcuate ligament; probable PCL (& maybe ACL) involvement if there is no endpoint
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Varus Stress Test (25–30 degrees of flexion)

Steps: Patient is supine with the involved leg close to the edge of the table and the knee is flexed ~ 25–30 degrees; Examiner supports the lateral portion of the distal tibia with one hand while the other hand grasps the knee along the medial joint line; Examiner applies a lateral (varus) force to the knee & the distal tibia is moved medially while the knee is in 25–30 degrees of flexion
Positive Test: Increased laxity, pain, and guarding
Positive Test Implications: Injury to the LCL; No end point indicates a Grade 3 injury; solid end point with no laxity but pain indicates a Grade 1 injury
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Lachman's Test

Steps: Patient is supine with his/her knee passively flexed to approximately 20 degrees & hands crossed across his/her chest; Examiner's thumb of the same–side hand as the knee to be examined is placed at the anterior medial tibial plateau/joint line, while digits 2–5 are positioned posterior, slighty distal to the popliteal fossa; Examiner's contralateral hand is placed laterally around the distal femur, just proximal to the patella with the thumb anterior & the digits 2–5 are positioned posteriorly; Examiner sets the tibia by pushing posterior (to make sure the PCL is in tact); Examiner provides an anterior force to the tibia while applying posterior pressure to the femur; repeats the process 2–3 times
Positive Test: Increased anterior tibial translation, pain
Positive Test Implications: ACL tear (primary posterolateral bundle but also the anteromedial bundle)
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NOTE: The student may also use the Thigh Bolster modification to stabilize the femur.

Posterior Lachman's Test

Steps: Patient is supine with his/her knee passively flexed to approximately 20 degrees & hands crossed across his/her chest; Examiner's thumb of the same–side hand as the knee to be examined is placed at the anterior medial tibial plateau/joint line, while digits 2–5 are positioned posterior, slighty distal to the popliteal fossa; Examiner's contralateral hand is placed laterally around the distal femur, just proximal to the patella with the thumb anterior & the digits 2–5 are positioned posteriorly; Examiner sets the tibia by pushing anterior (to make sure the ACL is in tact); Examiner provides a posterior force to the tibia while applying anterior pressure to the femur; repeats the process 2–3 times
Positive Test: Increased posterior tibial translation, pain
Positive Test Implications: PCL tear
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NOTE: The student may also use the Thigh Bolster modification to stabilize the femur.

Anterior Drawer Test

Steps: Patient is lying supine with his/her hip flexed 45 degrees & knee flexed 90 degrees; Examiner sits on the patient's foot & grasps the tibia just below the joint line; Examiner's thumbs are placed along the joint line on either side of the patellar tendon & the index fingers are used to palpate the hamstring tendons; Examiner ensures that the patient is relaxed, esp. the hamstring tendons; Examiner draws the tibia straight forward (no rotation)
Positive Test: Increased anterior tibial translation, pain
Positive Test Implications: ACL tear (mainly the anteromedial bundle because the posterolateral bundle is basically laxed in this position)
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Posterior Drawer Test

Steps: Patient is lying supine with his/her hip flexed to 45 degrees & knee flexed to 90 degrees; Examiner sits on the patient's foot & grasps the tibia just below the joint line; Examiner's thumbs are placed along the joint line on either side of the patellar tendon; Examiner ensures that the patient is relaxed, esp. the quadriceps; Examiner pushes the tibia posteriorly
Positive Test: Increased posterior tibial translation, pain
Positive Test Implications: PCL tear
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Posterior Tibial Sag Test

Steps: Patient is lying supine with his/her hip flexed to 45 degrees & knee flexed to 90 degrees; Examiner sits on the patient's foot & grasps the tibia just below the joint line; Examiner's thumbs are placed along the joint line on either side of the patellar tendon; Examiner ensures that the patient is relaxed, esp. the quadriceps; Examiner pushes the tibia posteriorly
Positive Test: Increased posterior tibial translation, pain
Positive Test Implications: PCL tear
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Quad Activating Test

Steps: Patient is lying supine with his/her hip flexed to 45 degrees & knee flexed to 90 degrees; Examiner observes the tibial tubercles for presence of a posterior sag; Examiner holds the patient's feet down against the table; Examiner instructs the patient to contract his/her quadriceps as if trying to straighten his/her knees; Examiner observes the tibial tubercle for anterior shifting upon quadriceps contraction
Positive Test: Anterior shift of the tibia upon quadriceps contraction
Positive Test Implications: ACL injury (if no posterior sag is present); PCL injury (if posterior sag is present)
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Slocum Drawer Test (ALRI)

Steps: Patient is lying supine with his/her hip flexed to 45 degrees & knee flexed to 90 degrees; Examiner internally rotates the tibia 25 degrees; Examiner ensures that the patient is relaxed, esp. the hamstrings; Examiner sits on the patient's foot & draws the tibia anteriorly
Positive Test: Increased amount of anterior tibial translation with tibial internal rotation
Positive Test Implications: Sprain of the lateral joint capsule, ACL, and LCL(int. rotation) (plus other possible lateral structures)
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Slocum Drawer Test (AMRI)

Steps: Patient lying supine with hip flexed to 45 degrees & knee flexed to 90 degrees; Examiner externally rotates the tibia 15 degrees to test for AMRI; Examiner ensures that the patient is relaxed, esp. the hamstrings; Examiner sits on the patient's foot & draws the tibia anteriorly
Positive Test: Increased amount of anterior tibial translation with tibial external rotation
Positive Test Implications: Sprain of the MCL, anteromedial capsule, & ACL (ext. rotation) (plus other possible medial structures)
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Lateral Pivot Shift Test (ALRI)

Steps: Patient is supine with his/her hip passively flexed to 30–45 degrees and slightly abducted; Examiner grasps the distal lower leg and/or ankle & maintains ~20 degrees of tibial internal rotation; While maintaining internal rotation, examiner applies a valgus force to the knee while slowly flexing & extending
Positive Test: A palpable "clunk" occurs as the tibia's position on the femur reduces as the leg is flexed between 30–40 degrees & anteriorly subluxes during extension
Positive Test Implications: Sprain of the lateral joint capsule, ACL, and LCL(int. rotation) (plus other possible lateral structures)
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Hughston External Rotation Recurvatum Test (PLRI)

Steps: Patient lies supine with the lower limbs relaxed; Examiner grasps the 1 st MT of each foot & lifts both feet off of the examining table; Examiner instructs the patient to keep his/her quadriceps relaxed & observes the tibial tuberosities
Positive Test: Affected knee goes into relative hyperextension on the lateral side with the tibia & tibial tuberosity rotating laterally
Positive Test Implications: Sprain of the lateral joint capsule, PCL, and can involve the LCL (plus other possible lateral structures)
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McMurry's Test

Steps: Patient is supine; Examiner stands lateral & distal to the involved knee with one hand supporting the lower leg; Examiner positions thumb & index finger of the opposite hand in the anteromedial & anterolateral joint lines on either side of the patellar tendon; Examiner keeps the tibia in the neutral position, applies a valgus stress through knee flexion & varus stress through knee extension; Examiner internally rotates the tibia & applies a valgus stress through knee flexion & a varus stress through knee extension; Examiner externally rotates the tibia & applies a valgus stress through knee flexion & a varus stress through knee extension
Positive Test: Popping, clicking, or locking of the knee; pain from within the joint
Positive Test Implications: Possible meniscus tear
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Bounced Home Test

Steps: Patient lies supine on the table; Examiner cups the patient's heel in his/her hand; Examiner flexes the patient's knee & allows the knee to passively extend
Positive Test: Knee extension is not complete or has a rubbery ("springy block") end feel; pain & guarding
Positive Test Implications: Possible meniscus tear (pain & springy block); Possible posterior capsular sprain (pain & guarding but no springy block
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Apley's Compression Test

Steps: Patient is prone with his/her knee flexed to 90 degrees; Examiner applies pressure to the plantar aspect of the heel, applying an axial load to the tibia while simultaneously internally & externally rotating the tibia
Positive Test: Pain; possible clicking
Positive Test Implications: Possible meniscus tear
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Apley's Distraction Test

Steps: Patient is prone with his/her knee flexed to 90 degrees; Examiner grasps the lower leg & stabilizes the knee proximal to the femoral condyles; Examiner distracts the tibia away from the femur while internally & externally rotating the tibia
Positive Test: Pain from Apley's compression is reduced and/or eliminated during distraction; Pain occurs with distraction & rotation
Positive Test Implications: Possible meniscus tear with decreased pain // joint capsule or ligament sprain with increased pain
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Wilson Sign Test

Steps: Patient is sitting with the knee flexed 90 degrees; Patient is instructed to internally rotate the knee and to maintain that position while extending the knee; Patient is instructed to stop knee extension at a point of pain, hold the knee at that point of motion, and then instructed to externally rotate the lower leg
Positive Test: Pain with internal rotation but a decrease in pain with external rotation
Positive Test Implications: Possible chondral or osteochondral defect of the joint
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Ober's Test

Steps: Patient is lying on the side opposite that being tested; Examiner stabilizes the pelvis with one hand and the lateral side of the examiner's hip against the patient's pelvis; Examiner grasps the femur above the knee with the other hand & abducts & extends the hip; Examiner allows the hip to passively adduct to the table with the knee straight
Positive Test: Leg does not adduct past parallel
Positive Test Implications: IT Band tightness
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Noble Compression Test

Steps: Patient is supine with the knee flexed; Examiner is positioned lateral to the patient on the involved side; Examiner supports the knee above the joint line with the thumb over or just superior to the lateral femoral condyle; Examiner applies pressure over the lateral femoral condyle, while the knee is passively extended & flexed
Positive Test: Pain underneath the thumb as the knee approaches 90 deg
Positive Test Implications: IT Band inflammation
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Patellar Apprehension Test

Steps: Patient lies supine with his/her quadriceps fully relaxed; Examiner attempts to move the patient's patella laterally as far as possible with the patient's legs fully extended; Examiner flexes the knee ~ 30 degrees & attempts to move the patient's patella laterally as far as possible
Positive Test: Patient forcefully contracts quadriceps and/or demonstrates apprehension, c/o pain
Positive Test Implications: Patellar subluxation/medial patellar retinaculum sprain
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Q Angle Test

Steps: Patient is lying supine with the knee fully extended; Examiner identifies & marks the ASIS, midpoint of patella & tibial tuberosity; Examiner places a goniometer so that: (a) Axis is located over the patellar midpoint; (b) The center of the stationary arm is over the line from the ASIS to the patella; (c) Moving arm is placed over the line from the patella to the tibial tuberosity
Positive Test: Q angle > 13 degrees (men) / 18 degrees (women)
Positive Test Implications: Increased lateral forces at the patellofemoral joint
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Medial–Lateral Patellar Glide Test

Steps: Patient is supine & fully relaxed with the involved knee placed on a bolster so that it is flexed ~ 30 deg; Examiner glides the patella medially & laterally, taking care to avoid tilting
Positive Test: Hypomobile patella (< 1 quadrant); hypermobile patella (> 3 quadrants)
Positive Test Implications: Lateral or medial patellofemoral joint laxity depending on which side is stressed

Clark's Sign Test

Steps: Patient is lying supine with the knee in 30 degrees of flexion; Examiner places one hand on top of the patella & applies gentle downward pressure; Examiner asks patient to contract the quadriceps muscle while applying a downward pressure on the patella; Examiner repeats this test but with the knee flexed to 60 degrees
Positive Test: Patient experiences patellofemoral pain & cannot hold the contraction
Positive Test Implications: Chondromalacia patella
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Stutter Test

Steps: Patient is sitting with his/her knee flexed over the edge of the table; Examiner stands lateral to the involved side, lightly cupping one hand over the patella; Examiner has the patient slowly extend his/her knee
Positive Test: Irregular patellar motion / stuttering between 40–60 deg
Positive Test Implications: Symptomatic medial synovial plica
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Hughston Plica Test

Steps: Patient is supine with his/her knee flexed to 90 degrees; Examiner internally rotates the tibia & passively moves the patella medially while palpating the anteromedial capsule; Examiner flexes & extends the knee from 90 degrees to 0 degrees while the tibia is internally rotated
Positive Test: Pain and/or palpable clicking
Positive Test Implications: Symptomatic medial synovial plica
See Test