The document describes various clinical tests used to evaluate the ligaments and structures of the knee. It begins by describing tests of the patella like the patellar glide test and patellar tilt test. It then discusses various drawer tests of the ACL like the Lachman test and pivot shift test. Further tests described include the quadriceps active test for the PCL, posterolateral drawer test, and McMurray test for meniscal injuries. Imaging options like x-ray, CT, MRI, and surgery procedures are also summarized.

1. Special Tests of Knee
Patellar Glide test
Knee flexed 20-30o, quadriceps relaxed
Patella divided into quadrants and displaced in medial and lateral directions to assess
tightness of parapatellar structures
Medial glide of 1 quadrant = tight lateral structures
Patellar Tilt test
Knee extended, quadriceps relaxed
Examiner lifts lateral edge of patella from the lateral femoral condyle
Tight lateral structures indicated in neutral or negative angle to the horizontal
A-P drawer
First inspect to determine if there is any posterior sagging (may get false positive anterior
drawer in a knee that is really PCL deficient)
Knee at 90o, do anterior drawer in neutral as well as 30o IR and 15o ER
In ER, medial complex should become tight; abnormal laxity = injury to posteromedial
corner
In IR, lateral complex should tighten and in the normal knee reduce anterior drawer;
abnormal laxity = injury to posterolateral corner
The IR/ER part is called the Slocum test
Lachman test
Perform an anterior drawer test at 15 degrees of flexion
The most sensitive test for ACL deficiency
Flexion Rotation Drawer Test
Anterior force is applied to the tibia in 15o of flexion, resulting in anterior subluxation as
in the Lachman test
With further knee flexion the tibia reduces beneath the femur with a clunk and internal
rotation of the femur
Pivot Shift
3 requisites: non functioning ACL, an intact medial complex and an intact iliotibial tract
Foot held in internal rotation with one hand and the leg slightly abducted, the other hand
is placed on the lateral side of the leg at the level of the fibular head
Apply a valgus thrust to the leg and gently flex it

2. If positive, subluxation will reduce at 20-30o with the lateral femoral condyle sliding
forward on the tibial plateau to a reduced position
Jerk Test
Start with the knee flexed and apply a valgus and IR force to sublux the lateral tibial
condyle anteriorly
As the knee is extended the tibia reduces with a clunk
Quadriceps Active Test
Patient supine, knee flexed to 90o, foot flat on the table
In the PCL deficient knee, tibia assumes a resting position posterior to normal
Quadriceps contraction against resistance produces anterior tibial translation
Dynamic Posterior Shift Test
Leg positioned with the hip at 90o flexion and knee is slowly extended from 90o of
flexion; Tibia is in a posteriorly subluxed position
In PCL insufficiency, as the knee extends, suddenly reduces with a clunk
Posteromedial Pivot Shift
Elicited by flexing the knee more than 45 degrees, while applying a varus stress,
compression and IR
As the knee is brought into extension, the tibia suddenly reduces, ~ 20-40 degrees short
of full extension
To be positive, PCL, MCL and posterior oblique ligament should be divided
External Rotation Recurvatum Test
Patient being supine, lift the legs by the great toe
Positive, when knee falls into varus hyperextension and tibial ER
Hughston stated this test to be specific for injury to the arcuate complex (LCL, arcuate
ligament, popliteus, lateral gastrocnemius)
Insall believes that the test will be mildly positive with isolated injury to the
posterolateral corner, but for excessive hyperextension and varus to be present, ACL
must be torn and possibly the PCL too
Posterolateral Drawer Test
Perform posterior drawer test, with knee at 90o flexion and foot 15o ER
If positive, lateral tibial plateau moves posteriorly on the femoral condyle; in contrast, the
medial condyle does not move
When asymmetrical = pathological ER of tibia

3. When the posterolateral structures are sectioned, ER of tibia increases ~5o at 90o of
flexion
When the PCL is torn, ER at 90o flexion increases another 15o ,if this test grossly
positive, PCL is probably damaged
Reverse Pivot Shift Test
Elicited by bringing the knee from a position of 90o flexion, where it is subluxed, to the
fully extended position under a valgus load and foot externally rotated, where it reduces
Jakob test is grossly positive in 3% and weakly positive in 8% of normal knees
This has been found to correlate with ligamentous laxity
When the test is asymmetrical comparing to other side or reproduces symptoms, indicates
posterolateral instability
External Tibial Rotation
Prone, knees at 30o and at 90o, foot is forcefully rotated externally
The degree of rotation of the medial border of the foot is measured relative to the
femur and compared with the contralateral side
Palpate the tibial plateau to determine its relative position to the femoral condyles; this is
to confirm that the increased ER is due to posterolateral instability rather than
anteromedial instability
There is considerable inter-individual variation in degree of maximal ER at 30o flexion:
average 30o, range 15-45o .At 90o flexion: average 37o, range 15-70o
Meniscal Tests
Numerous rotation tests for meniscal pathology have been described
All have the common purpose of trapping abnormally mobile or torn fragments of
menisci between the joint surfaces, causing pain or clicking
McMurray Test
Intended to diagnose lesions of the posterior horn of the meniscus
Patient supine, hip flexed 90o and knee flexed more than 90o
For examining the right knee, the examiner stands to the patient's right side with left hand
on the knee and right hand holding the foot
The foot is taken from a position of abduction and ER to one of adduction and IR
This is repeated for various angles between full flexion and 90o ,trapping of damaged
meniscus is felt as a clunk by the fingers on the joint line

4. Imaging tests
X-ray. Your doctor may first recommend having an X-ray, which can help detect bone
fractures and degenerative joint disease.
Computerized tomography (CT) scan. CT scanners combine X-rays taken from many
different angles, to create cross-sectional images of the inside of your body. CT scans can
help diagnose bone problems and detect loose bodies.
Ultrasound. This technology uses sound waves to produce real-time images of the soft
tissue structures within and around your knee, and how they are working. Your doctor
may want to maneuver your knee into different positions during the ultrasound, to check
for specific problems.
Magnetic resonance imaging. MRI uses radio waves and a powerful magnet to create 3D images of the inside of your knee. This test is particularly useful in revealing injuries to
soft tissues such as ligaments, tendons, cartilage and muscles.
Surgery
If you have an injury that may require surgery, it's usually not necessary to have the operation
immediately. Before making any decision, consider the pros and cons of both nonsurgical
rehabilitation and surgical reconstruction in relation to what's most important to you. If you
choose to have surgery, your options may include:
Arthroscopic surgery. Depending on your injury, your doctor may be able to examine
and repair your joint damage using a fiber-optic camera and long, narrow tools inserted
through just a few small incisions around your knee. Arthroscopy may be used to remove
loose bodies from your knee joint, remove or repair damaged cartilage, and reconstruct
torn ligaments.
Partial knee replacement surgery. In this procedure (unicompartmental arthroplasty),
your surgeon replaces only the most damaged portion of your knee with parts made of
metal and plastic. The surgery can usually be performed with a small incision, and your
hospital stay is typically just one night. You're also likely to heal more quickly than you
are with surgery to replace your entire knee.
Total knee replacement. In this procedure, your surgeon cuts away damaged bone and
cartilage from your thighbone, shinbone and kneecap, and replaces it with an artificial
joint made of metal alloys, high-grade plastics and polymers.