QEP Student Critical Thinking Rubric (updated 3-25-20) NO PARTIAL CREDIT

Date: July 5 & 6, 2020 Course: Clinical Orthopedics Evaluators: M. Hall, P. McCabe, Hamilton

Activity or Assignment: Practical Student: ______________________________________

Traits or Does Not Meet Does Not Meet Meets Expectations Exceeds Exceptional
Expectations at
Dimensions all. Expectations (average) Expectations
(below average) (above average)
GRADE 0 F = <69 C = 70-79 B = 80-89 A = 90-100
30% Did nothing. 0-10pts: Performed correct test and was it as taught?
Psychomotor / Knows
Execution: nothing.
What & how 0-5pts: Instructions to Pt. - Patient Positioning & Response (compensation), As taught?
Did not
the test is Optimum Stabilization – Safety, Instructions, Empathy, Personal Space & boundaries?
show up.
done.
No
0-10pts: Precision and firmness or sloppy and lose. Would the test have demonstrated
submission!
any yield of clinically pertinent findings?

0-5pts: Looks for Pt. compensation / Reaction?

70% 0-15pts: Purpose of the TEST – The test performed, and interpretation matched each
Description & other. Why are you doing this test and what are you looking for?
Interpretation
of Test:
Outcome &/or 0-10pts: Anatomy (Target accuracy) & Patho-anatomy?
finding.

0-5pts: Physiology & Pathophysiology?

0-5pts: Biomechanics & Patho-mechanics?

0-15pts: How the patient responds. What to look for?

0-15pts: What does the doctor feel for (perception)?

0-5pts: Variables – what constitutes a true positive (intent of test) and recognize other
clinically significant findings. Do they support the patient’s chief complaint?
Lumbar:

1- Passive Straight Leg Raise (SLR)

1. Have the patient supine on the table.

2. Doctor stands on the side of the leg being raised. Uninvolved first.
3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making
sure, that the knee remains locked in extension.
4. Doctor slowly & passively lifts the patient’s leg until symptoms are reproduced or exacerbated.
Not to exceed 90°. Try to document angle with inclinometer.
5. Repeat on involved side.
6. After a response, the doctor attempts to localize symptoms.

If the pain is mostly back pain then it is most likely a central disc herniation pressing on the anterior theca (ǂ) (*) of
the cord (back pain only = smaller & more central prolapses).
There is less LBP & Leg Pain when the discopathy is at L4-5.
There is more LBP & Leg Pain when the discopathy is at L5-S1.
If radicular pain happens on the other side, it’s called a Well Leg Raising test or Crossed/Contralateral SLR Test or
Fajersztajn = posterior medial HNP on the other side.

2- Bragard’s

1. Have the patient supine on the table.

2. Doctor stands on the side of the leg being raised. Uninvolved first.
3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the
knee remains locked in extension.
4. Doctor slowly & passively lifts the patient’s leg until symptoms are reproduced or exacerbated. Not to exceed
90°.
5. Once symptoms are reproduced or exacerbated the doctor backs off until symptoms subside (which is about 5°)
and holds that position.
6. Doctor then slowly & passively dorsi-flexes the Ankle until symptoms return.
7. Repeat on involved side.
 8. After a response, the doctor attempts to localize symptoms.

These are just confirming tests.

3- Bonnet’s

1. Have the patient supine on the table.

2. Doctor stands on the side of the leg being raised. Uninvolved first.
3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the
knee remains locked in extension.
4. Doctor slowly & passively lifts the patient’s leg until symptoms are reproduced or exacerbated. Not to exceed
90°.
5. If no response or only a mild response is noted then the doctor internally rotates to the entire leg.
6. If no response or only a mild response is noted then the doctor adds cross body adduction to the entire leg.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.

The Bonnet test uses hip adduction and internal rotation during SLR to help identify nerve root/sciatic irritation.
Internal rotation of the hip stretches the piriformis muscle and can influence sciatic nerve tension.
Hip adduction increases stretch on the sciatic nerve as it passes through the pelvic region.

4- Crossed or Contralateral Straight Leg Raise, Well Leg Raising Test, Fajersztajn’s

1. Have the patient supine on the table.

2. Doctor stands on the side of the uninvolved leg being raised.
3. Doctor then places their hand under the ankle of the leg to be lifted. The other hand is making sure that the
knee remains locked in extension.
4. Doctor slowly & passively lifts the patient’s leg until symptoms are reproduced or exacerbated down the
involved side. Not to exceed 90°. Try to document angle with inclinometer.
5. After a response, the doctor attempts to localize symptoms.
The Fajersztajn test is a confirmatory test for C-SLR test.
Fajersztajn = posterior medial HNP (Herniated Nucleus Pulposus) on the other side
5- Bechterew, Sitting SLR, Sitting Lasègue

1. Patient is sitting on the edge of the table with legs hanging free.
2. Perform on uninvolved leg first.
3. The lower leg is extended (Passively or Actively) until symptoms are reproduced or exacerbated. Not to exceed
90° of hip flexion.
4. Repeat on involved side.
5. After a response, the doctor attempts to localize symptoms.
6. If the patient leans back and places their hands behind them (usually oblique to the test side) then this is termed
Tripod Sign = Hamstring Contractures
7. If Tripod Sign happens quickly and somewhat dramatically then this is termed Flip Sign.

6- SLUMP Test

1. Patient is sitting UP STRAIGHT on the edge of the table with legs hanging free.
2. Popliteal areas against the table.
3. Arms behind their back with hands clasped.
4. Doctor checks for sacrum to be vertical and remain vertical throughout the procedure.
5. Doctor standing to the side of the patient.
6. Next have the patient slump forward at the thoracic and lumbar spine keeping the head & cervical spine
extended. (thoracic and lumbar flexion is the SLUMP component)
7. Are symptoms are reproduced or exacerbated?
8. Then the doctor places their anterior free hand on the patient’s forehead and has the patient SLOWLY tuck
their chin to their chest as the doctor controls the speed and amplitude of the neck flexion by the doctors’
posterior hand.
9. See if it changed any of their symptoms, reproduced or exacerbated?
10. The anterior hand is freed up to deal with the lower extremity.
11. The posterior hand that lies over the patient’s C-T junction & occiput and is preventing release of cervical flexion
rather than applying overpressure into flexion.
12. Then the lower leg of the uninvolved leg first is extended (Passively or Actively) until symptoms are reproduced
or exacerbated.
 13. Then Passively or Actively apply dorsiflexion to the foot until symptoms are reproduced or exacerbated.
14. Repeat #12 & #13 on the involved side.
15. After a response, the doctor attempts to localize symptoms.

The Slump Test is used to evaluate the dynamics of the neural structures of the central and peripheral nervous systems
from the head, along the spinal cord and sciatic nerve all the way down through its extensions into the foot.

Symptoms of sciatic pain or reproduction of the patient’s symptoms indicates a positive test, implicating impingement of
the dura and spinal cord or nerve roots.

7- Kemp’s

1. The patient is standing.

2. The doctor is standing behind the patient slightly off to one side.
3. The doctor places their thumb at the site in question (level & side). Right on right and left on left.
4. Test uninvolved side first. Example: doctors’ right thumb is placed over the patients’ right area of the L-S facets
(area in question).
5. Doctors left hand is placed on the patients’ left shoulder to control movement.
6. With the doctors left hand he puts the patient into RLF 1 st.
7. Then he extends the patient.
8. Then he contralaterally rotates (Right Rotation) the patient’s torso so they are leaning in a posterior oblique
position to the right until leg symptoms are reproduced or exacerbated.
9. Repeat #4 & #8 on the involved side.
10. After a response, the doctor attempts to localize symptoms.
Kemp’s test is a test to assess the lumbar spine facet joints. It is a provocative test to detect
pain, which can be local, referred or radiculair.
Homolog = Maximum Cervical Compression with contralateral rotation. We view Kemp’s as a provocative maneuver to
decrease the size of the IVF and recreate or exacerbate radicular symptoms down in the leg, especially below the knee.
This would be a positive Kemp’s. If it does not do this, then it is a negative Kemp’s. If there is only local pain about the
compromised structures, it is still a negative Kemp’s but clinically significant for structural issues most likely the “Z” joint.
Kemp’s has a sensitivity of 70% [1] but that is for combined radicular and local symptoms. Differentials are Stenosis
(central & IVF), DJD, DDD, IVF stenosis creating neurogenic claudication. Pain is seen in the back, buttock and thigh along
with heaviness & weakness and reduced strength & feeling of the leg. Provocation is seen with standing, walking and
lumbar extension. With all this said its diagnostic accuracy has come into question.
The Kemp test uses lateral bending with extension and rotation of the thoracolumbar spine into and away from the
direction of antalgia (see below). Many rotate ipsilaterally to the side of leg symptoms. Example: right sided symptoms -
Kemp’s with Lumbar extension + RLF + RR. Ipsilateral rotation causes a decrease in foraminal size although not
significantly due to limited lumbar rotation. We choose to use contralateral rotation because it causes facet impaction +
extension causing facet imbrication + lateral bending to decrease the size of the IVF. To further decrease the size of the
IVF we try to compress the spine downward through the shoulders if possible.

Correlating the antalgic lean, the side of leg pain, and the symptoms while maneuvering into and away from antalgia
assists the examiner in determining if a lateral or medial disk protrusion is present during the Kemp test. Example:
Patient has a Left sided radiculopathy. In one scenario their antalgic lean is to the right as this is the only position that
gives them a modicum of relief. If you were to perform Kemp’s to the left it would exacerbate their radiculopathy. The
thinking here is that they have a Left lateral disc protrusion. In the next scenario their antalgic lean is to the left as this is
the only position that gives them a modicum of relief. If you were to perform Kemp’s to the right it would exacerbate
their radiculopathy. The thinking here is that they have a Left medial disc protrusion. My problem with some of this is
lumbar roots have different courses as they exit the foramen. Make sure you can localize via your neuro-exam.
If there is more pain (local-LBP) when leaning forward there is a greater strain / sprain component.

8- Prone Knee Bend, Femoral Nerve Stress Test, Nachlas, Ely’s and Modified Ely’s
Femoral Nerve Tension
1. The patient is prone.
2. The doctor is standing to the side of the table. Perform on the opposite side of symptoms first.
3. Doctor grasps the patients’ ankle and passively & slowly flexes the patients’ lower leg taking the heel towards
the same buttock = Nachlas.
4. Doctor grasps the patients’ ankle and passively & slowly flexes the patients’ lower leg taking the heel towards
the opposite buttock = Ely’s.
5. Doctor grasps the patients’ ankle and passively & slowly flexes the patients’ lower leg taking the heel towards
the opposite buttock then adds hyperextension of the thigh = Modified Ely’s.
6. Prone Knee Bend and Femoral Nerve Stress Test are performed the same as Nachlas.
7. Repeat on the side of symptoms.
8. All are done until symptoms are reproduced or exacerbated.
9. LPB &/or SI pain = + Nachlas & Ely’s
10. Neurological symptoms in the anterior upper thigh = + Modified Ely’s, Prone Knee Bend and Femoral Nerve
Stress Test (done side lying).
11. Duncan-Ely (not listed above) allows one to measure the angle of the Tibia relative to the table at that point
when the ASIS raises off the table = Tight Rectus Femoris. This may be seen while performing the other tests.
The patient lies prone while the examiner passively flexes the knee as far as possible so that the patient’s heel rests
against the buttock. At the same time, the examiner should ensure that the patient’s hip is not rotated. If the
examiner is unable to flex the patient’s knee past 90° because of a pathological condition in the knee, the test may
be performed by passive extension of the hip while the knee is flexed as much as possible. Unilateral neurological
pain in the lumbar area, buttock, posterior thigh or sometimes the anterior thigh may indicate an L2 or L3 nerve root
lesion.
This test also stretches the femoral nerve. Pain in the anterior thigh indicates tight quadriceps muscles or stretching
of the femoral nerve. A careful history and pain differentiation help delineate the problem. If the rectus femoris is
tight, the examiner should remember that taking the heel to the buttock may cause anterior torsion to the ilium,
which could lead to sacroiliac or lumbar pain. The flexed knee position should be maintained for 45 to 60 seconds.
Butler has suggested modifications of the PKB test to stress individual peripheral nerves.
If the hip spontaneously flexed with knee flexion= rectus femoris contractute
9- Spring Test, Anterior Glide, P-A - Shear / Translation

1. The patient is prone.

2. The doctor is standing to the side of the table.
3. Starting above or below the segment in question.
4. Doctor places their hypothenar eminence (knife edge) perpendicularly over the spinous process and reinforced
with the other hand.
5. Apply a gentle but firm force in a P-A direction.
6. Check for differences in motion (quantity & quality).
7. See if symptoms are reproduced or exacerbated.
Positive - Increased or decreased motion at one vertebra compared to another (hyper or hypo mobility) and pain
maybe elicited.
Pain is a sign of local joint dysfunction.

10- Prone Instability Test

1. The patient is prone and has slid down to where their ASIS’s are on the bottom edge of the table.
2. The doctor is standing to the side of the table localizes the segment in question as above from the Spring test.
3. The doctor maintains his contact over the area but without force.
4. Doctor instructs the patient to lift both feet off the floor just enough to clear the floor.
5. The doctor reapplies a gentle but firm force in a P-A direction over the segment again.
6. See if symptoms are reduced or abated.
The examiner applies pressure to the posterior aspect of the lumbar spine while the patient rests in this
position. The patient then lifts the legs off the floor, and the examiner again applies posterior compression to
the lumbar spine. If pain is elicited in the resting position only, the test is positive, because the muscle action
masks the instability.
If the act of lifting their feet off the floor causes pain without your over pressure you are probably looking at an
issue of muscular strain. If the pain is reduced by actively raising the legs off the ground; then the patient can
 actively stabilize the lumbar spine which makes this a positive test and would most likely benefit from a lumbar
stability program.

Pelvic:

11- A-SLR
1. Patient is supine on table.
2. Doctor is at the foot of the table.
3. Doctor instructs the patient to actively raise one leg approximately 20cm off the table and hold it there
for at least 5 seconds. Without bending the knee.
Doctor observes for compensatory patterns of trunk rotation and an increase in SI pain usually contralateral to
the side being tested (Possible SI joint problem)

12- Iliac - Compression (gap posterior)

SI joint dysfunction (Compression of anterior SI, tensile stress to posterior SI)
1. Patient is Side lying on the table. Have them move back towards you.
2. Doctor is Standing to the side of the table behind the patient.
3. Make sure the patients’ shoulder and pelvis are in line with each other and perpendicular to the table.
4. Doctor contacts the lateral aspect of the patients’ ASIS with a reinforced calcaneal hand contact.
5. Doctor applies gentle and steady lateral to medial pressure straight down towards the table.
6. Allow patient to respond and look for reproduction or exacerbation of the patient’s symptoms.

13- Distraction (gap anterior)

SI joint dysfunction (Compression of posterior SI, tensile stress to anterior SI)
1. Patient is Supine on the table.
2. Doctor is Standing to the side of the table facing the patient.
3. Doctor contacts the anterior aspect of both of the patients’ ASIS’s with a calcaneal hand contact.
4. Doctor applies gentle and steady anterior to posterior pressure straight down towards the table.
5. Allow patient to respond and look for reproduction or exacerbation of the patient’s symptoms.
14- Gaenslen’s
Applies torsional stress on the SI joints
1. Patient is Supine on the table to the side closest to you.
2. Doctor is Standing to the side of the table facing the patient.
3. Doctor instructs the patient to flex the opposite knee towards the chest while palpating for the lumbar
lordosis to reduce.
4. When it first touches the doctors’ hand they are told to stop and grab the knee to maintain it.
5. The doctor then pivots the patient so the leg that is closest to the doctor falls off the table.
6. The doctor then places one hand on top of the patients’ hands holding their flexed knee and the other
is placed over the thigh that is off the table and applies downward pressure.
Allow patient to respond and look for reproduction or exacerbation of the patient’s symptoms.

Pain in the sacroiliac joints is indicative of a positive test.

15- Thigh Thrust
Applies anteroposterior shear stress on the SI joint this will also look for femoral acetabular issues of the
posterior capsule (posterior dislocation, Labral tears etc.).
1. Patient is Supine on the table.
2. Doctor is Standing to the side of the table facing the patient.
3. The doctor then passively flexes the patients’ leg closest to him to 90°.
4. He then adducts the thigh to force the pelvis to raise allowing access to palpate over the patients’ SI.
5. He then returns the pelvis to the table op top of the doctors’ hand.
6. The doctor then places the patients’ knee towards his axilla and applies axial pressure straight down
towards the table feeling for motion.
7. Allow patient to respond and look for reproduction or exacerbation of the patient’s symptoms.
 For a test to be positive, it must reproduce the patient’s typical pain in their SI joint region.
16- Sacral Thrust
1. Patient is prone on the table.
2. Doctor is positioned to the side of the table facing the patient.
3. The doctor takes their inferior hand using a midline calcaneal contact and places it over the patients S3
segment with the fingers pointing cephalad.
4. The doctor then reinforces the contact with their superior hand.
5. The doctor then gently but firmly pushes P-A & S-I over the sacrum.
6. Allow patient to respond and look for reproduction or exacerbation of the patient’s symptoms.

Interpretation: + with local SI Joint pain on suspected side.

HIP:

17- Patrick-FABERE
1. Patient is supine on table.
2. Doctor is at the side of the table.
3. Doctor flexes the patient’s thigh, then abducts and externally rotates it. The leg is crossed over the
other leg with the ankle just above the patient’s patella.
4. Doctor places one hand over the knee and the other stabilizes over the patients ASIS.
5. Doctor applies slight downward pressure to the knee (extension).
6. Doctor looks for the patient to respond.

A negative test is indicated by the test leg’s knee falling to the table or at least being parallel with the
opposite leg. A positive test is indicated by the test leg’s knee remaining above the opposite straight
leg. If positive, the test indicates that the hip joint may be affected, that there may be iliopsoas spasm,
or that the sacroiliac joint may be affected.
18- FADDIR
This test is used to test for anterior–superior impingement syndrome, anterior labial tear, and iliopsoas
tendinitis.
1. Patient is supine on table.
2. Doctor is at the side of the table.
3. Doctor flexes the patient’s thigh, then adducts and internally rotates it.
4. Doctor looks for the patient to respond.

A positive test is indicated by the production of pain, the reproduction of the patient’s symptoms with
or without a click, or apprehension.

19- OBER’s #2
Ober’s test assesses the tensor fasciae latae (iliotibial band) for contracture
1. Patient is side lying bottom hip & knee flexed to stabilize the pelvis.
2. Doctor stabilizes the hip and keeps the pelvis perpendicular to the table.
3. While holding the ankle the doctor flexes the knee and raises the thigh until it is parallel.
4. While holding the ankle the doctor raises the knee slightly and allows it to drop. (don’t let it hit the
other leg)
5. Doctor observes for any contracture.

If a contracture is present, the leg remains abducted and does not fall to the table.

KNEE:

20- Apley’s Distraction

1. Patient is prone on the table.
2. Doctor stands on the side of the leg being distracted with the leg bent to 90°.
Uninvolved first.
3. Doctor interlaces their fingers and then places their hands around the patient’s lower
leg but superior to the malleoli.
4. Doctor places their superior knee on the patient’s thigh.
 5. Doctor applies an upward traction to the leg then internally and externally rotates it.
6. Wait for a response from the patient.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.

Then pull up or distract and maintain traction while simultaneously internally and
externally rotating the lower leg. If rotation is more painful and/or shows an increase
in rotation relative to the other side, then the problem is more ligamentous.

21- Apley’s Compression

1. Patient is prone on the table.
2. Doctor stands on the side of the leg being compressed with the leg bent to 90°.
Uninvolved first.
3. Doctor places their hands over the patients heal and applies a downward force.
4. Doctor then internally and externally rotates it.
5. Wait for a response from the patient.
6. Repeat on involved side.
7. After a response, the doctor attempts to localize symptoms.
 Then push down or compress on the lower leg to compress the joint and then
internally and externally rotate the lower leg. If rotation compression is more painful
and/or shows a decrease in rotation relative to the other side, then the problem is
more meniscal in nature.

22- McMurry’s (original)

1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor bends the patient’s leg to bring the heel as close as possible to the patients’
buttocks.
4. Lower leg is internally rotated then extended.
5. Process is repeated with external rotation.
6. Repeat on involved side.
7. After a response, the doctor attempts to localize symptoms
 Start with Maximal Knee Flexion + Internal/medial rotation of the Tibia + Varus
Stress = Palpate with free hand over lateral joint line for pop or click = Lateral
Meniscus (posterior portion)
 Start with Maximal Knee Flexion + External/lateral rotation of the Tibia + Valgus
Stress = Palpate with free hand over medial joint line for pop or click = Medial
Meniscus (posterior portion)
Pain and tenderness on the medial joint line indicate medial meniscus
pathology.
 Flexion + IR of Tibia + Varus + Extension = Pop / Click & Pain = Tear of the
Lateral Meniscus
 Flexion + ER of Tibia + Valgus + Extension = Pop / Click & Pain = Tear of the
Medial Meniscus

23- Varus
Stability tests / ligamentous Tests
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested with the patient’s leg against their
hip. Uninvolved first.
3. Doctor places the calcaneal portion of their inferior hand over the medial joint line.
Drop the forearm to be perpendicular to the joint.
 4. The superior hand stabilizes just above the lateral femoral condyle.
5. Doctor then applies a medial to lateral force.
6. Check for excessive motion and wait for a response from the patient.
7. Raise the leg up into 20°-30° flexion and repeat.
8. Repeat on involved side.
9. After a response, the doctor attempts to localize symptoms.

With extension varus stress one also checks LCL, Posterolateral capsule, Arcuate-
popliteus complex, Biceps femoris tendon, ACL & PCL, Lateral Gastrocnemius muscle.
24- Valgus
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested with the patient’s leg against their
hip. Uninvolved first.
3. Doctor places the calcaneal portion of their superior hand over the lateral joint line.
Drop the forearm to be perpendicular to the joint.
4. The inferior hand stabilizes just below the medial tibial plateau.
5. Doctor then applies a lateral to medial force.
6. Check for excessive motion and wait for a response from the patient.
7. Raise the leg up into 20°-30° flexion and repeat.
8. Repeat on involved side.
9. After a response, the doctor attempts to localize symptoms.
With extension valgus stress one also checks MCL (superficial & deep), Post. Oblique Lig. (POL),
Posterior medial capsule, ACL & PCL, Medial quadriceps expansion (Vastus medialis {obliquus
& longus}), Semimembranosus muscle.

25- Anterior Drawer (Active)

1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor bends the patient’s leg to 45°at the hip & 90°at the knee and then sits on the
foot.
4. Doctor observes tibial plateau to see if has fallen posteriorly under the femoral
condyles.
5. If it has, have the patient contract their quads and see if the tibial plateau comes
anteriorly to a normal position.
6. If it has not, have the patient contract their quads and see if the tibial plateau comes
anteriorly excessively.
7. If bent knee alignment is normal and contraction of the quads does nothing, then
there is nothing wrong.
8. Check for excessive motion and wait for a response from the patient.
9. Repeat on involved side.
10.After a response, the doctor attempts to localize symptoms.
 o If when relaxed in the above position before the test is done a large
depression or “Sag” is noted infrapatellarly this is due to a PCL tear
(Grade 3 more than likely).

o If there is no posterior Sag and the tibia shifts anteriorly on the injured
side than the noninjured side, this + for ACL disruption (injured >
noninjured = ACL disruption).

26- Anterior Drawer (Passive)

This tests the ACL for anterior instability
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor bends the patient’s leg to 45°at the hip & 90°at the knee and then sits on the
foot.
4. Doctor places their index fingers behind in the popliteal space and their thumbs on
either side of the infrapatellar tendon crossing the joint space.
5. Doctor then pulls the tibial plateau anteriorly.
6. Checks for excessive motion and wait for a response from the patient.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.
27- Posterior Drawer (Passive)
This tests the PCL for posterior instability.
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor bends the patient’s leg to 45°at the hip & 90°at the knee and then sits on the
foot.
4. Doctor places their thenar eminences over the tibial tuberosity and their thumbs on
either side of the infrapatellar tendon crossing the joint space.
5. Doctor then pushes the tibial plateau posteriorly.
6. Checks for excessive motion and wait for a response from the patient.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.
 Backward movement of tibia about <5-6mm is normal). >6mm will mean that other
structures are injured to some degree also.

28- Lachman
The Lachman test, which may also be referred to as the Ritchie, Trillat, or Lachman-Trillat test,
is the best indicator of injury to the anterior cruciate ligament, especially the posterolateral
band
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor places their superior hand anteriorly just above the patella.
4. The inferior hand reaches to the posterior-medial tibial plateau.
5. Raise the leg up into 10°-20° flexion.
6. Doctor then pulls and applies a P-A with a slight medial to lateral force.
7. Check for excessive motion and wait for a response from the patient.
and repeat.
8. Repeat on involved side.
9. After a response, the doctor attempts to localize symptoms.

Some feel this is the best indicator of an ACL injury (especially posterolateral band).
 A “+ Lachman” is seen with ACL (posterolateral bundle), Post. Oblique Lig. (POL), and
Arcuate-popliteus complex. There are many different variations on how to do this test but the
same stress is being created by all.

29- Grinding (Clarkes Sign)

1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor takes a web contact on the superior border of the patient’s patella and
applies a S-I & A-P pressure.
4. The patient is then asked to contract their quads drawing the patella under the
doctor’s contact.
5. Repeat on involved side.
6. After a response, the doctor attempts to localize symptoms.

The test is positive if they have retro-patellar pain and they cannot hold the
contraction. Although the test is not very specific for any one pathology, it is better if
it is done at full extension, 30°, 60° and 90°. When + it is generally felt to be an early
sign of Patello-Femoral Arthralgia (PFA), AKA: Patello-Femoral Pain Syndrome. PFA
used to be called chondromalacia patellae.

30- Lateral Pivot Shift Maneuver (Test of Macintosh)

This is the primary test used to assess ALRI of the knee and is an excellent test for ruptures
(third-degree sprains) of the anterior cruciate ligament
1. Patient is supine on the table.
2. Doctor stands on the side of the leg being tested. Uninvolved first.
3. Doctor bends the patient’s leg to 90°at the hip and 90°at the knee.
 4. The doctor then dorsiflexes the foot and internally rotates it with the inferior hand.
5. The superior hand is placed over the lateral aspect of the knee.
6. Doctor then applies a L-M (valgus stress) pressure through the joint line with their
MCP joints and a P-A pressure with their thumb on the fibular head.
7. The leg is brought down into extension while maintaining pressure in all areas.
8. Repeat on involved side.
9. After a response, the doctor attempts to localize symptoms.
This is the primary test of the primary restraints to test for Antero-Lateral Rotary Instability
(ALRI) and is very good for detecting third degree sprains/rupture of the ACL.

31- Thessaly’s
This is kind of an active meniscal grinding test.
1. Patient is standing and asked to raise one leg and place the foot behind the
popliteal space.
2. Doctor is in front of the patient supporting the patient by holding their hands.
3. Patient is asked to bend their knee and lower themselves about 5°.
4. Patient is then asked to rotate fully, all the way to the left and then the right 3
times.
5. See if there is any response from the patient.
6. Patient is asked to bend their knee and lower themselves about 20°.
7. Patient is then asked to rotate fully, all the way to the left and then the right 3
times.
8. See if there is any response from the patient.
9. Repeat on involved side.
10.After a response, the doctor attempts to localize symptoms
If they experience medial or lateral joint line discomfort it is considered + for a meniscal tear.
They may also experience locking or catching.

ANKLE:

32- Anterior Drawer

8. Patient is supine on the table with their heels slightly off the edge of the table.
9. Doctor stands on the lateral side of the ankle being tested. Uninvolved first.
10. Doctor lifts and maintains the patient’s foot in dorsiflexion with his inferior forearm.
11. Doctor then reaches to the medial side of the patients heel and cups it with his inferior hand.
12. The superior hand supports the distal leg at the mortice (talocural) joint.
13. The doctors inferior hand pulls up with the heel against the resistance of his superior hand.
14. Doctor awaits a response from the patient and feels for excessive glide.
15. Process is repeated with plantarflexion and slight inversion.
16. Doctor stands on the medial side of the ankle being tested.
17. Doctor allows the patient’s foot to plantarflex naturally.
18. This position is maintained with his inferior forearm laying on top of the foot which also places it in
slight inversion.
19. Doctor then reaches to the lateral side of the patients heel and cups it with his inferior hand.
20. The superior hand supports the distal leg at the mortice (talocural) joint.
21. The doctors inferior hand pulls up with the heel against the resistance of his superior hand.
22. Doctor awaits a response from the patient and feels for excessive glide.
23. Repeat on involved side.
24. After a response, the doctor attempts to localize symptoms.
 This test is designed primarily to test for injuries to the anterior talofibular ligament, the most
frequently injured ligament in the ankle.

33- Talar Tilt

1. Patient is supine on the table with their heels slightly off the edge of the table.
2. Doctor stands inferiorly to the ankle being tested. Uninvolved first.
3. With the doctor’s upper abdomen forcing the patient’s foot into dorsiflexion and maintaining it
there.
4. Doctor grasps the patient’s heel bilaterally with his thenar eminences just underneath the malleoli,
thumbs pointing downward, fingers cupping the heel and elbows akimbo.
5. Doctor now controls talar inversion (Varus) and talar eversion (Valgus) and the only way to move is
for the doctor to swing back and forth.
6. Doctor awaits a response from the patient and feels for excessive movement.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.
34- E.R.S.T. (External (Lateral) Rotation Stress Test )(Kleiger)
1. Patient is sitting on the table. (Patient seated with the leg hanging over the side at 90°)
2. Doctor stands on the lateral side of the ankle being tested. Uninvolved first.
3. Doctor grasps both the mid-foot & fore-foot and then dorsiflexes the ankle with one hand.
4. The thenar eminence of the other hand is placed upon the lateral aspect of the calcaneus.
5. The foot is then fully externally rotated.
6. Doctor awaits a response from the patient and feels for excessive movement.
7. Repeat on involved side.
8. After a response, the doctor attempts to localize symptoms.

If pain is produced over the anterior & posterior tibio-fibular ligaments and interosseous
membrane, then they have a syndesmosis (high ankle) injury.
Pain over the deltoid ligament (medial malleolus) indicates injury, and pain over the lateral
malleolus indicates injury to the syndesmosis.
The test is positive for a syndesmosis (“high ankle”) injury if pain is produced over the anterior or posterior
tibiofibular ligaments and the interosseous membrane. If the patient has pain medially and the examiner feels the
talus displace from the medial malleolus, it may indicate a tear of the deltoid ligament.