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HIPMNRS
Basic introduction to regional exam performed by Dr. Vizniak
video resources: palpation, muscle testing, ROM
regional exam forms – Rehab. & Stretching patient handouts
To learn more see our text books or take our hands on training seminars
Anterior Posterior Drawer Test
Patient supine with knee bent 90°, examiner stabilizes foot with hip & places thumbs over the anterior knee joint line & pulls the tibia anteriorly
(+) Pain → Anterior cruciate ligament sprain
(+) Excessive motion → Anterior cruciate rupture
Degrees of knee joint instability
- Grade I – mild, < 5 mm of translation
- Grade II – moderate, 5-10 mm of translation
- Grade III – severe, > 10 mm translation
This test shows higher sensitivity values when performed on non-acute knee injuries (sn: 18-95 sp: 86-100 +LR: 1.8-8.3 -LR: 0.1-0.5)
Valgus & Varus Stress Test
Valgus Test Procedure (Abduction Stress Test)
Patient supine with legs straight, examiner stabilizes medial ankle & applies a lateral to medial (valgus) force at the knee, procedure is then repeated with the knee slightly flexed (~25°)
(+) Pain → Medial (tibial) collateral ligament sprain
(+) Increased motion/gapping → Medial (tibial) collateral ligament rupture
Varus Test Procedure (Adduction Stress Test)
Patient supine with legs straight, examiner stabilizes lateral ankle & applies a medial to lateral (varus) force at the knee, procedure is then repeated with the knee slightly flexed (~25°)
(+) Pain → Lateral (fibular) collateral ligament strain
(+) Increased motion/gapping → Lateral (fibular) collateral ligament rupture
Collateral ligament injury classification
- I 0-5 mm of joint opening, no instability
- II 5-10 mm of joint opening, mild instability
- III 10-15 mm, moderate instability
- IV > 15 mm of joint opening, severe instability
Lachman's Test
Patient supine with knee bent 15°-30°,
Lachman’s Anterior: examiner stabilizes the patient’s femur with one hand & then pulls the tibia anteriorly with the other hand
Lachman’s Posterior: same procedure except repeated with the examiner pushing the tibia posteriorly
(+) Pain with normal anterior translation → ACL sprain
(+) Pain with increased anterior translation → ACL rupture
(+) Pain with normal posterior translation → PCL sprain
(+) Pain with increased posterior translation → PCL rupture
This procedure is considered the gold standard for the evaluation of anterior cruciate & posterior cruciate knee ligament damage (r: 0.38 sn: 63-99 sp: 42-100 +LR: 2.15 -LR: 0.23)
Apley's Compression Test
Patient prone with knee flexed 90°, examiner applies downward force on the foot & rotates internally/externally
(+) Pain or crepitus with compression & rotation, which is relieved by knee distraction → Meniscal damage (r: 0.95 sn: 13-16 sp: 86-100 +LR: 0.8-5.9 -LR: 0.63-1.1)
Signs of a meniscal lesion:
- Knee joint line pain
- Popping or grating (crepitus) soundésensation with movement
- “Locking” of the knee (inability to fully extended)
Apley’s compression test should be followed with a hyperflexion compression test if a meniscal lesion is suspected
Squat Walk Test
If possible, have patient get into a low squat and ‘walk’ forward – this is a better variation for to increase pressure on knee using patient’s own body weight – (+) joint line pain or inability to perform task → meniscal damage
Bounce Home Test
Patient supine & relaxed, examiner lifts straight leg & bends knee to approximately 20° by placing a hand behind the popliteal fossa, examiner then proceeds to remove support from the posterior knee allowing it to drop into full extension (bounce home)
Interpretation
(+) Joint line pain → Meniscal tear
(+) Inability to fully extend knee:
- Spongy end-feel → Swelling/edema
- Rubbery end-feel / pain → Meniscal tear (r: 0.07-0.29 sn: 38-47 sp: 67-85 +LR: 1.2-2.9 -LR: 0.0.7-0.9)
Steinmann's Test
Patient supine with hip flexed 90° & knee flexed 90°, examiner palpates around the knee joint line & proceeds to flex & extend the knee while palpating the joint
(+) Pain with movement & crepitus → Meniscal lesion (r: 0.05 sn: 29 sp: 100)31, 89, osteochondritis dissecans, ligament sprain
This maneuver is essentially passive knee ROM with the examiner palpating the joint (a useful technique to employ with all passive ROM procedures)
Patellar Apprehension Test
Patient supine with legs straight & quadriceps muscles relaxed, examiner gently & slowly pushes the patella laterally & observes the patient for signs of verbal & nonverbal apprehension or reflex quadriceps contraction
(+) Apprehension or reflex quadriceps muscle contraction → Patellar instability, subluxation, tracking disorder, patellofemoral dysfunction
Some clinicians suggest having the knee flexed 30° during this maneuver; with the knee flexed, the patella is much more stable in the patellar groove of the femur (increasing of a false negative), testing with leg straight increases the clinically validity of the test (sn: 7-37 sp: 86-100 +LR: 0.9-2.3 -LR: 0.8-1)
Patellar Facet Pinch Test
Patient supine with 
legs straight & quadriceps muscles relaxed, examiner gently & slowly pushes the patella laterally & palpates the facets, the test is then repeated with the examiner pushing the patella medially
(+) Facet tenderness → Chondromalacia patella
Perkin’s Sign: peripheral patellar tenderness upon medial & lateral displacement
Patellar Grind Test
Synonym: Patellar Grind Test, Clarke’s Sign
Patient supine legs straight, examiner “cups” hand over patella & applies a downward force (compressing the patella against the femur), examiner then proceeds to move the patella laterally, medially, superiorly, inferiorly, & in a twisting motion (“twist & grind”)
(+) Pain and/or crepitus → Chondromalacia patella, DJD, osteochondritis of the patella, patellar fracture (sn: 29-49 sp: 67-75 +LR: 0.9-1.9 -LR: 0.7-1.1)73, 81, 82, 71
Compression of the patella on the femur may cause pain due to aggravation of inflamed or damaged tissues. Many patients may have a feeling of nausea or apprehension (warn patient ahead of time)
Clarke's Test
Patient supine with leg straight, examiner compresses the quadriceps muscle 2 cm (1 inch) above the superior pole of the patella, the patient is then instructed to contract the quadriceps muscle
(+) Retropatellar pain → Chondromalacia patella, degeneration of the patellofemoral joint
Contraction of the quadriceps compresses the patella against the femoral condyles
Chondromalacia patella causative factors; recurrent patellar dislocation, patella alta & other congenital anomalies, quadriceps muscle imbalance, increased Q-angle at the knee, direct patellar trauma
McMurray's Test
Patient supine or side-lying with hip flexed at 90° & knee flexed 90°, examiner stabilizes patient’s knee over distal quadriceps muscles & grips patient’s heel with the other hand & applies long axis compression; examiner then rotates the tibia internally while applying a varus force, examiner then rotates the tibia laterally while applying a valgus force
(+) Pain or crepitus → Meniscal lesion
- Valgus force with external rotation → Lateral meniscus
- Varus force with internal rotation → Medial meniscus
Signs of a meniscal lesion: knee joint line pain, crepitus sensation with movement, “locking” of the knee
Surgical confirmation of McMurray’s test has show that it can be less than 75% accurate. Beware false positives or negatives & cluster with other tests
This test is difficult to perform correctly & takes lots of practice & regular use to be proficient
(r: 0.16-0.35 sn: 16-67 sp: 69-98 +LR: 1.5-9.3 -LR: 0.38-0.86)
Nobel's Test
Patient supine or side-lying, examiner applies lateral to medial pressure over the patient’s lateral epicondyle with thumb & slowly flexes & extends the leg (3-4 times)
(+) Pain over the lateral femoral epicondyle or palpable tendon snapping → Iliotibial band syndrome
Etiologic factors in ITB syndromes:
- Pelvic tilt, running or cycling on an oblique surface
- Increased activity, sudden increase in running or cycling distance; Varus knee deformity, overpronation
- Leg length inequality (may be related to pelvic tilt)
Rinne Test
Patient standing, examiner applies pressure over the patient’s lateral epicondyle with thumb & instructs patient to squat & rise or step up on to a bench
(+) Pain over the lateral femoral epicondyle or palpable tendon snapping → Iliotibial band syndrome
This maneuver provides a more functional weight bearing assessment of the iliotibial band, but it should be noted that the net movement at the knee is the same as Noble’s compression test performed with the patient side-lying or supine
Do NOT confuse this test with the Rinne test for hearing function
Duck Waddle Test
Patient standing with feet approximately ~30 cm apart & legs maximally internally rotated, patient then attempts a full squat; maneuver is repeated with patient’s legs externally rotated
(+) Pain, inability to perform test, audible “clicking” or crepitus →
- With internal rotation → Lateral meniscus tear
- With external rotation → Medial meniscus tear
Procedure provides functional weight bearing assessment of potential knee pathologies (sn: 64-67 sp: 81-90 +LR: 3.5-6.4 -LR: 0.4)
Disco/Thessaly Test
Patient standing on a single leg near wall, examiner instructs patient to twist from side to side, test may be repeated with support & weight bearing knee flexed 5° & again at 20° flexion
(+) Pain, inability to perform maneuver, audible “clicking” or crepitus on weight bearing knee → Knee joint pathology, arthritis, meniscal lesion, ligamentous strain, internal derangement
Examiner should provide patient with some support (hold hands) or be ready to catch the patient should they lose their balance
Increased knee flexion may improve diagnostic accuracy (r: 0.95 sn: 66-92 sp: 91-97 +LR: 9-30 -LR: 0.08-0.35)
Follow HIP-MNRS with every patient encounter – History, Inspection, Palpation – Motion, Neurovascular, Referred, Special Tests
Make sure you have a detailed anatomy understanding and can create a list of potential pain generators (muscle, bone, joint, ligament, cartilage, blood vessels, nerves, viscera & lymphatics) – any competent practitioner should be able to give a detailed list of the anatomy below their hand and the tissues they are stretching, compressing or activating
Clinicians performing regional exams must realize that no one sign is of absolute significance in isolation, each individual finding should be evaluated only in the context of other findings & the patient as a whole; this is particularly important with diagnostic procedures that may result in “soft” signs, which are difficult to reproduce & may have a large subjective bias in their interpretation.
When recording test results it is not enough to write “test-X positive.” Record any findings associated with the test (reproduction of symptoms, pain, muscle guarding, numbness & tingling, decreased flexibility, clicking, etc) – more information results in a more accurate assessment & better treatment. Remember assessment is therapeutic! – to learn more see out text books or take our hands on training seminars
References