OBJECTIVE ASSESSMENT:HYPOTHESIS TESTING.

Msc Manual TherapyThe Knee

Observation

Swelling:Diagnosed by MRI.Self reported swelling and Ballottment test best to

identify effusion (Kasteline, 2009).62% certainty if negative.Alignment:Q-angle.Anteversion/retroversion.Valgus/Varus.Patella position.Muscle bulk/tone.Leg length.

Functional test

GaitSquatSingle leg dipStep upStep downKneelHopFunctional activity relevant to agg and ease.Differential tests

Active Movements

FlexionExtensionMedial rotation

through rangeLateral rotation

through range

RepeatSustainCombine movementsSpeed alterationDifferentiate

arthrogenic, myogenic, neurogenic.

Passive Movements

FlexionExtensionMedial rotationLateral rotationF/Ab and F|Ad quadrantE/Ab and E/Ad quadrantOverpressureSustained

Muscle function

IsometricIsotonicThrough range strengthPNFFlexibilityCore stability

Meniscal Tests

Joint effusion, McMurrays and JLT combined may result in superior diagnostic accuracy (Scholten et al 2001)

Good history and several clinical tests may provide greater diagnostic accuracy than a specific physical test. Don't seem to apply to acutely injured knees, or those with degenerative menisci (Callaghan, Best Bet, 2008).

Summary of sensitivity and specificity

Test Sensitivity SpecificityMcMurray’s 16-70% 59-98%JLT 55-95% 15-97%Bounce Home 36-47% 67-86%Apley’s 13-41% 80-93%Thessaly’s 65-92% 80-97%Ege’s 64-67% 81-90%Composite 11-100% 77-99%

Meniscus evaluation should include McMurrays and JLT. Thessaly’s test has shown promise but future research is required to define it’s diagnostic accuracy (Chivers, 2009).

Lachmans

ACL tests

Best acute ACL test

Best on field test(+) test is a

“mushy” or “empty” end-feel

False (-) if tibia is IR or femur is not properly stabilized

(+) Test is increased anterior tibial translation over 6 mm

(+) test indicates: ACL (anteromedial bundle) posterior lateral capsule posterior medial capsule MCL (deep fibers) ITB Arcuate complex

False (-) if only ACL is torn False (-) if there is swelling

or hamstring spasm False (+) if there is a

posterior sag sign present

Anterior Drawer Test

Lateral Pivot Shift Maneuver

Tests for ACL and posterolateral rotary instability Posterolateral capsule Arcuate complex

(+) test is the tibia reduces on the femur at 30 to 40 degrees of flexion, subluxation of the tibia on extension

Sensitivity and specificity

PCL tests

Posterior Drawer Test

Rubenstein, et al 1994 found posterior drawer test 90% sensitive for PCL injury.

58% for Quadriceps Active Test & 26% for Reverse Pivot Shift Test.

Clinical exam on whole was 96% effective in detecting PCL dysfunction

Posterior Sag Test

Tests for posterior tibial translation

Tibia “drops back” or sags back on the femur

Medial tibial plateau typically extends 1 cm anteriorly

(+) test is when “step” is lost

(+) Test indicates: PCL Arcuate complex ACL????

Valgus stress test

MCL

Assesses medial instability Must be tested in 0° and 30° (+) Test in 0°

MCL (superficial and deep) Posterior oblique ligament Posterior medial capsule ACL/PCL

(+) Test in 30° MCL (superficial) Posterior oblique ligament PCL Posterior medial capsule

Grading Sprains: 1-3

Varus Stress Test

LCL

Assesses lateral instability Must be tested in 0° and

20/30° flexion (+) Test in 0°

LCL Posterior Lateral Capsule Arcuate Complex PCL/ACL

(+) Test in 30° LCL Posterior lateral capsule Arcuate complex

Grading Sprains

Reverse Lachmans Dial Test

Prone, femur fixed.Ant drawer to end

point.+ve tib tuberosity

and fib head move lat.

Prone, knees flexed to 90˚.

Externally rotate feet.

+ve if effected foot moves ?15˚ more.

PLC

Valgus Stress Test Hyperextension

Full extension.20˚ flex.If increase in

movement think PLC.

In standing/walking will have ext/lat thrust.

Prone heels over bed: +ve if heel dropped.

Clarke’s (grind) test

No evidence.Many false

positives.+ve if reproduces

pain or unable to hold contraction.

Patellofemoral Tests

Compression test Apprehension test

Force patella into trochlea.

Monitor pain response.

Flex knee to 20-30˚.Laterally displace

patella.

Tibio femoral Tibio fibular

Tibia:

Femur:

Fibular head:

Accessrory Movements: neutral/through range

Patellofemoral

Round the clockRotation

Other joints/structures

LumbarThoracicSIJHipFoot and ankleNeural: PKB +/- slump, SLR +/- peroneal

nerve bias

Conclusion

Have you confirmed/negated your hypothesis/es?Have you indentified subjective and objective

markers for retesting ?What is your clinical impression?What is your prognosis for recovery?Formulate a treatment plan incorporating

comparable findings, functional difficulties, patient specific goals and best available evidence.

How will you progress treatment to ensure maximum recovery?