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KNEE
ANATOMY & CLINICAL TESTS
Dr Vimal Prakash
MBBS,MS,DNB
AIIMS Jodhpur
KNEE JOINT
•Tibiofemoral joint – modified
hinge joint
•Patellofemoral joint – saddle joint
•Articular (hyaline) cartilage covers
femoral condyles, tibial plateaus,
trochlear groove, and patellar
facets
Major stabilisers of tibiofemoral joint
Static stabiilisers Dynamic stabilisers
Tibiofemoral ligaments Qudriceps
Medial and lateral meniscus Hamstrings
Topography of articular surface Gastrocnemius
Loads across articular surface popliteus
• 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
OSSEOUS STRUCTURE
•DISTAL FEMUR
•Medial ,lateral condyles
•Rounded posteriorly , flat anteriorly
•Groove between condyles
Anteriorly - patellofemoral groove/trochlea
Posteriorly - Intercondylar notch
•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
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
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
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
Nerve supply
Articular branches from
•Femoral anteriorly
•Tibial nerve posteriorly
•Common fibular laterally
•Obturator and saphenous medially
Nerves in relation
•Tibial (L4-S3)
• CPN (L4-S2)
•Deep peroneal
•Superficial
peroneal
•Sural
•Saphenous
(L2-4)
Capsule
•surrounds all three articulations
•extends proximally into the
suprapatellar pouch.
•synovial lining also covers the cruciate
ligaments (making them intraarticular
but extrasynovial)
Bursae around knee
•suprapatellar
•prepatellar
•subcutaneous infrapatellar
•deep infrapatellar
•posterior (between muscle and bone)
• popliteal
• gastrocnemius
• semimembranosus
EXTRAARTICULAR TENDINOUS STRUCTURES
QUADRICEPS MECHANISM
HAMSTRINGS GROUP
GASTROCNEMIUS
POPLITEUS
ILIOTIBIAL BAND
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
•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.
Structures on lateral aspect
• Iliotibial tract
• Biceps femoris
Superficial
• Lateral
patellofemor
al ligament
• Lateral
patellar
retinaculum
Middle
• LCL
• Fabellofibular
ligament
• Popliteus
• Popliteofibular
ligament
• Capsule
• Arcuate
ligament
DEEP
Medial structures
• sartorius
• Fascia
Superficial
• Superficial MCL
• Posterior oblique
ligament
• Medial
patellofemoral
ligament
• Medial patellar
retinaculum
• Semimembranosus
• Pes anserinus
Middle
• Deep MCL
• Meniscofemoral fibres
• Meniscotibial fibres
• capsule
Deep
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 meniscus
3 origins
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
❑ 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
❑ 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
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
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
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
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
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.
INTRAARTICULAR STRUCTURES
•Anterior cruciate ligament
•Posterior cruciate ligament
•Medial and Lateral meniscus
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
•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
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
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
•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
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)
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
• 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
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
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
•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
•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.
•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)
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.
•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.
•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.
Axis around knee
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
•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
•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
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
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
•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
CLINICAL TESTS
TESTS FOR MENISCUS LIGAMENT STRESS TEST ROTARY TESTS
Mcmurrays test Valgus stress test Slocum Anterior Rotary Drawer Test
Apleys grinding test Varus stress test Jerk Test of Hughston and Losee
Squat test Anterior drawer test Lateral Pivot Shift Test of Macintosh
Thessaly test Lachman test Flexion-Rotation Drawer Test
Joint line tenderness Posterior drawer test External Rotation-Recurvatum Test
Quadriceps active test Reverse Pivot Shift Sign of Jakob,
Hassler, and Stäubli
Tibial External Rotation (Dial) Test
Posterolateral Drawer Test
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.
•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%
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%
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
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.
•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
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
•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
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
•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
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.
•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.
• 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
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.
•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
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.
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.
• 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
•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.
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
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.
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
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.
•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.
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.
•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
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.
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.
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
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).
•>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.
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
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Knee anatomy and clinical tests 2024.pdf

  • 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 meniscus Hamstrings Topography of articular surface Gastrocnemius Loads across articular surface popliteus
  • 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
  • 8.
  • 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 • capsule Deep
  • 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 meniscus 3 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.
  • 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 MENISCUS LIGAMENT STRESS TEST ROTARY TESTS Mcmurrays test Valgus stress test Slocum Anterior Rotary Drawer Test Apleys grinding test Varus stress test Jerk Test of Hughston and Losee Squat test Anterior drawer test Lateral Pivot Shift Test of Macintosh Thessaly test Lachman test Flexion-Rotation Drawer Test Joint line tenderness Posterior drawer test External Rotation-Recurvatum Test Quadriceps active test Reverse 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