Range Of Motion And Maneuvers

The principal movements of the knee are flexion, extension, and internal and external rotation. Ask the patient to flex and extend the knee while sitting. To check internal and external rotation, instruct the patient to rotate the foot medially and laterally. Knee flexion and extension can also be assessed by asking the patient to squat and stand up—provide support if needed to maintain balance.

You will often need to test ligamentous stability and integrity of the menisci, particularly when there is a history of trauma or palpable tenderness. Always examine both knees and compare findings.

Techniques for Examining the Knee

Structure

Medial collateral ligament (MCL)

Lateral collateral ligament (LCL)

Anterior cruciate ligament (ACL)

Structure

Medial collateral ligament (MCL)

Lateral collateral ligament (LCL)

Anterior cruciate ligament (ACL)

Maneuver

Abduction Stress Test. With the patient supine and the knee slightly flexed, move the thigh about 30° laterally to the side of the table. Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side (valgus stress).

Adduction Stress Test. Now, with the thigh and knee in the same position, change your position so you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push medially against the knee and pull laterally at the ankle to open the knee joint on the lateral side (varus stress).

Anterior Drawer Sign. With the patient supine, hips flexed and knees flexed to 90° and feet flat on the table, cup your hands around the knee with the thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings. Draw the tibia forward and observe if it slides forward (like a drawer) from under the femur. Compare the degree of forward movement with that of the opposite knee.

Pain or a gap in the medial joint line points to ligamentous laxity and a partial tear of the medial collateral ligament. Most injuries are on the medial side.

Pain or a gap in the lateral joint line points to ligamentous laxity and a partial tear of the lateral collateral ligament.

A few degrees of forward movement are normal if equally present on the opposite side.

A forward jerk showing the contours of the upper tibia is a positive anterior drawer sign and suggests a tear of the ACL..

Techniques for Examining the Knee (Continued)

Structure

Posterior cruciate ligament (PCL)

Medial meniscus and lateral meniscus

Posterior cruciate ligament (PCL)

Medial meniscus and lateral

Maneuver

Lachman Test. Place the knee in 15° of flexion and external rotation. Grasp the distal femur with one hand and the upper tibia with the other. With the thumb of the tibial hand on the joint line, simultaneously move the tibia forward and the femur back. Estimate the degree of forward excursion.

Posterior Drawer Sign. Position the patient and place your hands in the positions described for the anterior drawer test. Push the tibia posteriorly and observe the degree of backward movement in the femur.

McMurray Test. If a click is felt or heard at the joint line during flexion and extension of the knee, or if tenderness is noted along the joint line, further assess the meniscus for a posterior tear.

With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers and thumb along the medial and lateral joint line. From the heel, rotate the lower leg internally and externally. Then push on the lateral side to apply a valgus stress on the medial side of the joint. At the same time, rotate the leg externally and slowly extend it.

Significant forward excursion indicates an ACL tear.

Isolated PCL tears are rare.

A click or pop along the medial joint with valgus stress, external rotation, and leg extension suggests a probable tear of the posterior portion of the medial meniscus.

Palpate the gastrocnemius and soleus muscles on the posterior surface of the A defect in the muscles with lower leg. Their common tendon, the Achilles, is palpable from about the tenderness and swelling in a lower third of the calf to its insertion on the calcaneus. ruptured Achilles tendon; tender ness and thickening of the tendon above the calcaneus, sometimes with a protuberant posterolateral bony process of the calcaneus in Achilles tendinitis

To test the integrity of the Achilles tendon, place the patient prone with the knee and ankle flexed at 90°, or alternatively, ask the patient to kneel on a chair. Squeeze the calf and watch for plantar flexion at the ankle.

Absence of plantar flexion is a positive test indicating rupture of the Achilles tendon. Sudden severe pain "like a gunshot wound," an ecchymosis from the calf into the heel, and a flat-footed gait with absence of "toe-off" may also be present.

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