OBJECTIVE ASSESSMENT: HYPOTHESIS TESTING. Msc Manual Therapy The 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 Gait Squat Single leg dip Step up Step down Kneel Hop Functional activity relevant to agg and ease. Differential tests

Active Movements Flexion Extension Medial rotation through range Lateral rotation through range Repeat Sustain Combine movements Speed alteration Differentiate arthrogenic, myogenic, neurogenic.

Passive Movements Flexion Extension Medial rotation Lateral rotation F/Ab and F|Ad quadrant E/Ab and E/Ad quadrant Overpressure Sustained

Muscle function Isometric Isotonic Through range strength PNF Flexibility Core 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 TestSensitivitySpecificity McMurray’s16-70%59-98% JLT55-95%15-97% Bounce Home36-47%67-86% Apley’s13-41%80-93% Thessaly’s65-92%80-97% Ege’s64-67%81-90% Composite11-100%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 clock Rotation

Other joints/structures Lumbar Thoracic SIJ Hip Foot and ankle Neural: 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?