5/25/2016
George J. Davies, DPT, MED, PT, SCS, ATC, LAT, CSCS, NASM-PES, NASM-CES, ACSM-CET, APTA-CCI, SMAC, (REMT), FAPTA Thank You Professor of Physical Therapy, AASU, Savannah, GA. (2004- ) z Thanks to RUSH 2016 SPORTS Professor Emeritus UW-LaCrosse, WI. (1975-2004) Consultant, Clinician, Co-Director Clinical and Research Services– MEDICINE SYMPOSIUM for the Sports PT Residency Program , GLSM, La Crosse, WI. (1995-present) kind invitation to present at this Sports PT, Coastal Therapy, Savannah, GA. (2004- present) course Past President Sports Physical Therapy Section – APTA (1992-1998) JOSPT - Co-Founder & Co-Editor, 1979 JOSPT - GJD-JAG Excellence in Clinical Research Award, 2004 Fellow, APTA, 2005, Hall of Fame Award, SPTS-APTA, 2006 NATA, President’s Award, 2007, NATA, Most Distinguished Athletic Trainer, 2009 z It is indeed an honor and privilege Sports Health - Co-Founder & Co-Editor, 2009 to be invited to participate and AOSSM – Hall of Fame Award, 2013 share information.
Disclosures:
Disclosures: The following companies have Disclosures: provided research equipment support to Biodynamics & Human Associate Editor, Performance CenterCenter--AASU:AASU: ArthrometricsArthrometrics,, Atlanta, GA. Sports Health Editor Biodex, Shirley, N.Y. PUBMED CDM Sport/Monitored Rehab Elsevier-Book Royalties Systems, Fort Worth , TX . INDEX MEDICUS Human KineticsKinetics--BookBook Royalties ElsevierElsevier-- DS2 Rehab Systems, Missouri City, 2015 Williams & Wilkins-Wilkins-BookBook Royalties Book Royalties TX North American SeminarsSeminars--DVDDVD ERMI, Atlanta, GA. Royalties ExerToolsExerTools,, Petaluma, CA. Innovative Sports Inc, Chicago, IL. Conflicts TheraBandTheraBand,, Hygenic Corporation, No Conflicts Akron, OH. No Conflicts 2015
Disclosures: Casual interest in the “Gladly accept knee money from Examination anyone for for the last Institutional 51 years since I Research of the Support….” started as a student Knee athletic trainer in 1965 !!! No Conflicts
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Examination of the Knee Examination of z This is an article that we published the Knee: 38 years ago in the Physician and SportsMedicine that was used for CME’ s for physicians. How do we do z At that time it was ““statestate of the artart”,”, and it’s interesting how much it? of that that art has stayed the same, with of course, some changes! P & SM, 1978
Subjective Examination Knee Subjective, and History of the Knee Mechanism of Injury Complex Objective & Functional Examination
Subjective Exam Subjective Differential Diagnosis Components Exam Components z Diagnostic tests & Imaging Studies z Demographic information z Lab tests z Location of symptoms z DiDominan t arm z Medical systems review: questionnaire Systems review z MOI and interview (Differential DX.) and differential z History: present & past z Meds z Previous treatments z Behavior of symptoms: rest, ADL’s, diagnosis work, sports, AM/PM z Previous functional status z Patient’s goals
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Functional Testing Algorithm – Functional Testing Algorithm FTA Specific Guidelines Knee -2016 kSports Specific Tests z LEFT ––MM--1:30;1:30; FF--2:002:00 minutes z Sport Specific Testing Competitive kLower Extremity Functional Tests z HOP - < 10%Ht.; < 10% bilat.bilat. Comp.; z Lower Extremity Functional Norms/various hops Athletes kFunctional Hop Tests Tests z JUMP - < 15%/Ht.; Norms z Functional Hop Tests kFunctional Jump Tests z OKC Isokinetics - < 25% bilateral z Functional Jump Tests Recreational kOKC Isokinetic Tests comparison/other criteria z OKC Isokinetic testing Athletes kCKC Isokinetic Tests z CKC Isokinetics - < 30% bilateral comparison z CKC Isokinetic Testing kKinesthetic/Balance Tests z Sensorimotor System Testing: General z Kinesthetic/Balance Testing –Bilat Balance/Proprioceptive Orthopaedic kKT 1000 Tests comp Testing Patients kSpecial Tests – ONLY 175 + 1 z KT 1000 - < 3 mm bilateral comparison z KT 1000/2000 kBasic Measurements z Basic Measurements - < 10% bilateral z Basic Measurements comparison
Basic Measurements Basic Measurements zTime/soft tissue healing z MD Clearance & Approval zVAS (0-(0-1010 scale) z Time/soft tissue healing zAnthropometric z VAS (0(0--1010 scale) measurements z Anthropometric measurements zAROM, PROM z AROM, PROM z Special Tests zSpecial Tests z Qualitative & Quantitative zQualitative & Quantitative Movement Assessment Movement Assessment z Knee Rating scales: IKDC, etc. zKnee Rating scales: IKDC, etc.
Functional Testing Algorithm ACL Quad Tendon Dark Quad We still have not Tendon PrePre-- Graft Healing answered this Question? TIME: Op
Soft tissue healing from zBiologics and “mother nature” the i nj ury or anddth the:
from a zNeoangiogenesis zMaturation post-surgical condition Time Zero 1 month PO 6 months PO zLigamentization
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Functional Testing Algorithm Clinical Decision Making Clinical Decision Making TIME: Soft tissue healing We need similar types of outcomes regarding the biology of healing We can’t hurry “mother nature”; Although we are trying with all the biologics!!!
Clinical Decision Making Clinical Decision Making Basic Measurements zPerhaps wait for 3-6 z Hamstrings more months to allow Time/soft the biologics to “do their job”…. tissue
BTB healing
ACL Quad Tendon Dark Quad Clinical Decision Making Tendon PrePre-- Graft Healing Op Then we return him back to sports
Time Zero 1 month PO 6 months PO 1 year PO
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Physical Examination/ Physical Examination of the Physical Tests & Measurements Knee z Observation/ z Physiological PROM posture z Gait Evaluation z Accessory/Jt. Play 1) Most physical exam tests should PROM Q & Q Movement be referenced back to the original ((ObjectiveObjective)) z KT 1000 Assessment z Flexibility Tests description z Referral/related joints z RROM (MMT/HHD) z 2) Sensitivity z Neurological Exam z Special Tests EitiExamination z Computerized z Sensation, reflexes z 3) Specificity isokinetic testing z Kinesthetic/ proprioceptive z Functional Testing z 4) Likelihood ratios z Imaging Studies Balance z 5) PPV of the Knee z Lab Studies Neural TT z Palpation z 6) NPV z AROM
Functional Testing Algorithm – Functional Testing Algorithm – Functional Testing Algorithm – Knee -2016 Knee Knee z Progression to the next higher level of z Sport Specific Testing Competitive zObjective, quantitative (and z Lower Extremity Functional Athletes qualitative), systematic testing difficulty is predicated upon Tests passing the prior test in the series… z Functional Hop Tests testing and rehabilitation z Functional Jump Tests Recreational method to safely and rapidly z Each successive test and its associated z OKC Isokinetic testing Athletes progress a patient from training regimen places increasing z CKC Isokinetic Testing stress on the patient while at the same General immediate post injury/post-injury/post- z Sensorimotor System Testing: time decreasing clinical control Balance/Proprioceptive Orthopaedic op to return to full functional Testing Patients z KT 1000/2000 activities and return to play in z So how does it really work? z Basic Measurements sports
DC to Focused Within NOT Sports Functional Testing Algorithm – 30%30%--YESYES Within RehabRehab-- CKC 30% NOT Focused Knee Exercises Within Within Specificity 10%10%--YESYES CKC Power Norms Rehab zWe can rehabilitate patients Testing Specificity NOT Focused Testing faster than ever because by Within Within Focused RehabRehab-- NOT 10%10%--YESYES 10% Within RehabRehab-- testing themthem, we always know Balance Within NormsNorms-- Functional YES Norms Jump/Jump/HopHop whthtitiithhere the patient is in the SensoriSensori-- Exercises motor Functional rehab program and can focus testing Testing NOT Within the interventions specifically on Within Focused NOT Focused 10%10%--YESYES Rehab Within 25%25%-- Within 10% YES RehabRehab-- the patient’s particular 25% OKC Basic Exercises condition and status MeasureMeasure-- OKC ments Testing
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Physical Examination/ Tests & Measurements KT 1000 Tests z Observation/ posture z Physiological PROM Gait Evaluation z Accessory/Jt. Play PROM Q & Q Movement Assessment z KT 1000 Observation z Flexibility Tests z Referral/related joints z RROM (MMT/HHD) z Neurological Exam z Special Tests z Sensation, reflexes z Computerized & Posture isokinetic testing z Kinesthetic/ proprioceptive z Functional Testing Balance z Imaging Studies Neural TT z Lab Studies z Palpation z AROM
Gait Evaluation Q & Q Movement AAtssessment
Qualitative Movement Analysis of the Entire Kinematic Chain in all Planes of Motion
Regional Interdependency Basic Measurements Performance Tests z Qualitative & Quantitative Single Leg Step TOTAL BODY INTERDEPENDENCY Movement Assessment: Down Analysis If movement is one integrated z Step Down Tests: pattern, regardless of its complexity,
then we must evaluate and treat z The TOTAL PATIENT
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Axial Spinal “Clearing” Appendicular Peripheral Joint “Clearing” Tests Tests • Lumbar Spine Hip • AROM • PROM – End ROM • MMT – Mid ROM Proximal Tib-Fib Joint • Special Tests Ankle • SI Joint Foot
Neurological Exam-Exam-SensorimotorSensorimotor System Testing Knee Kinesthetic Testing •Balance •Sensation –dermatomes etc. •Balance •Reflexes •Angular Joint Replication •Neurodynamic testing •End ROM Reproduction •MMT •Threshold to Sensation of •Kinesthesia/Proprioception Movement
Biodex Clinical Balance It has been my clinical Biomechanics Stabilometer 17:55117:551--554,554, observation (performance 2002 motion assessment) that after a LE injury, individuals do not bear weight equally during double-double-legleg exercises, especially on the injured leg
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ACLACL--R ACTIVE ROM: •More flexion -WB- WB on ACL-ACL-RR side • More external weight --WBWB on ACL-ACL-RR side 1) Quantitative- 3 months: unweighted ACLCL--RR side Gonio met ry 6 months: unweightedACL- ACL-RR side 12 months: normalized WB --ACLACL--RR side 2) Qualitative
Majority of patients felt like they were performing equal WB on both legs
ACCESSORY Flexibility Tests – MOVEMENTS Lower Extremity JOINT PLAY MOVEMNT (Length Tests – MT COMP ONENT MOVEMENTS Unit) (Included in Special tests)
Knee Evaluation Criteria Springy Rebound Compliance ––HysteresisHysteresis Special Tests Examiner : z Elastic hysteresis: z A simple way to understand it is in terms of a Degree of laxity (translation) rubber band with weights attached to it. If the top of a rubber band is hung on a hook and small - End feel weights are attached to the bottom of the band one at a time , it will get longer . As more weights are - Hysteresis loaded onto it, the band will continue to extend because the force the weights are exerting on the band is increasing. When each weight is taken off, - Crepitus/grating or unloaded, it will get shorter as the force is reduced. As the weights are taken off, each weight - locking/pseudo-locking that produced a specific length as it was loaded onto the band now produces a slightly longer length as it is unloaded. This is because the band - clunk/click does not obey Hooke's law perfectly. The hysteresis loop of an idealized rubber band is shown in Fig. 3.
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Knee Evaluation Special Tests Corroboration of Criteria multiple tests z Patient – z Orthopedic Physical to identify z Patient c/o pain Assessment consistency in the (e(reprod uc tioofthetion of the z Magee, DJ symptoms) z > 175 special tests for the clusters of signs & z Knee ????????????? symptoms = z We’ll discuss and demonstrate z Patient c/o apprehension an algorithmalgorithm--basedbased exam for clinical diagnosis (feeling that the PFJ is ready the special tests which is to subluxate/dislocate) clinically efficient
Algorithm Based Exam Category Physical Examination of the Physical Examination of the Cluster of S & S YES KneeKnee--EffusionEffusion Tests -6- 6 KneeKnee--EffusionEffusion Tests
+ - NO Ballottement Test/Ballotable Patella or Patella Tap Test (SEN:83)(SP:49)(+LR:1.6) Category Sweep Test (Wipe , Brush , Bulge , Stroke YES Cluster of S & S Test) Fluctuation Test + - NO Indentation Test Peripatellar Swelling Test YES Category Palpable fluid wave Clusters of S & S
Physical Examination of the Physical Examination of the Physical Examination of the KneeKnee--MilkingMilking Test/Fluid Wave KneeKnee--PFPF Ballotment Test KneeKnee--PFPF Tests --3232
(SEN:83) (SP:49) (+LR:1.6)
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Physical Examination of the KneeKnee-- Physical Examination of the Physical Examination of the PatelloPatello--FemoralFemoral Tests KneeKnee--PatelloPatello--FemoralFemoral Tests KneeKnee--PFPF Glides (Med/Lat) Patellar Apprehension test (Fairbank’s Apprehension Test) (SEN:7-37)(70- 92)(+LR:0.87-2.3) Patellar Grinding Compression Test (Clarke’s sign) (SEN:29-49)(SP:67-95)(+LR:0.88- VMO Coordination Test (PF Tracking Test) 7.4) (SEN:17)(SP:93)(+LR:2.26) Active Patellar Grind Test Eccentric Step Test (SEN:42)(SP:82)(+LR:2.34) 2 QuadrantsQuadrants-- PF Medial Tilt (SEN:43)(SP:92)(+LR:5.4) McConnell Test for patellar Orientation PF Lateral Tilt PF Superior Tilt (SEN:19)(SP:83)(+LR:1.1) McConnell Test for Chondromalacia patella WNL PF Pos ter ior Tilt Zhl’Zohler’s Sign Medial PF Glides (SEN:54)(SP:69)(+LR:1.8) Tubercle Sulcus Test Lateral PF Glides (SEN:54)(SP:69)(+LR:1.8) Q-angle (SEN:76)(SP:63)(+LR:2.05) Caudal PF Glides (SEN:63)(SP:56)(+LR:1.4) Cephalic PF Glides Palpation Tests: (SEN:27-83)(SP:68-76)(+LR:1.11-1.5) Patellar Mobility Testing Resisted Knee Extension (SEN:21-39)(SP:82-95)(+LR:2.2-4.2) PF Rotations Pain with Functional Testing (SEN:75-94)(SP:43-50)(+LR:1.3-1.8) PF Passive Tracking Test PF Active Tracking Test Step Up Test Lateral Pull Test (SEN:25)(SP:100) Frund’s Sign (SEN:54)(SP:69) Waldron Test (SEN:18-45)(SP:68-83)(+LR:1.05-1.41) Dynamic Apprehension Test (SEN: 100)(SP: 88) Patella Alta Test (SEN:49)(SP:72)(+LR:1.75) VMO Coordination Test (PF Tracking Test) (SEN:17)(SP:93)(+LR:2.26) (+LR:1.8)
Physical Examination of the KneeKnee-- Physical Examination of the PF Caudal & Cephalic Glides KneeKnee--PFPF Tilts (Med/Lat)
15 -WNL - WNL
Caudal Glide Cephalic Glide Medial Tilts: (SEN:63) (SP:56) (SEN:43)(SP:92) (+LR:1.4) 10 mmmm--WNLWNL (+LR:5.4)
Physical Examination of the KneeKnee--PFPF Passive Tracking
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Physical Examination of the Physical Examination of the Physical Examination of KneeKnee--PFPF Active Tracking KneeKnee--PFPF CKCCKC--AROMAROM Tracking the KneeKnee--PCLPCL Tests --1919
(SEN:25) (SP:100)
Physical Examination of the KneeKnee-- Physical Examination Physical Examination of the Posterior Instability Tests of the Knee KneeKnee--RecurvatumRecurvatum Test Posterior Drawer Test (SEN:22-100)(SP:99)(+LR:90) External Rotation - Recurvatum test (SEN:3-39)(SP:99)(+LR:3.0) Valgus test at 0° knee extension (SEN:59-94)(SP:100) Varus test at 0° knee extension PCL TESTS Posterior Sag Sign (Gravity Drawer Test) (SEN:46-100)(SP:100) Godfrey’s 90/90 Test Clancy’s Step-off Test/Thumb Sign QdiQuadriceps AtiDActive Drawer Tt(STest (Sen-54-98%) (Spec-97-100%)(+LR: 18) Reverse Pivot Shift (Jakob Test)(PLRI) (SEN:26-58)(SP:94-95)(+LR:5.2-9.67) Posterior (Reverse) Lachman’s Test/Trillat’s Test (SEN:62)(SP:89)(+LR:5.64) Dial Test (Tibial External Rotation Test) Anterior Abrasion Sign (SEN:7-14)(SP:NA) Posterior Drawer Test Fixed Posterior Subluxation Proximal Tibial Percussion Test Posterior Functional Drawer Test Loomer’s Test (PLRI) Dial Test (PLRI/PCL) (SEN:3(SEN:3--39)39) Standing Apprehension Test (SP:99) Posterior Medial Displacement Test (PMRI) NoulisNoulis’’ Thesis, 1875 (+LR:3.0)
Physical Examination of the Physical Examination Physical Examination of the KneeKnee--SAG/Godfrey’sSAG/Godfrey’s Test of the Knee KneeKnee--Clancy’sClancy’s Step - Up Test PCL TESTS It is important to establish the starti ng refe re nce po sitio n so we do not mis-mis-interpretinterpret the tibial translation (10mm = Normal) (SEN:46(SEN:46--100)100) (Step(Step--upup is lost = + PCL injury) 10 mm (SP:100) StepStep--UpUp - WNL
11 5/25/2016
Physical Examination Physical Examination of the Physical Examination of the of the Knee KneeKnee--PosteriorPosterior Drawer Test Knee PCL TESTS PCL TESTS Posterior Drawer Test When positioning the knee at 7070°°,, oftentimes Posterior Drawer Test the tibia will sag posteriorly due to gravity . When the Post Drawer Test is performed, no posterior translation occurs; because the Recommended a 7070°°knee angle position tibia is already posteriorlyposteriorly subluxatedsubluxated.. Therefore, the test may appear negative Meniscus can act as “chock blocks” because there is no posterior displacement. (SEN:22(SEN:22--100)100) (Primary vs Secondary restraints) (SP:99) (+LR:90)
Physical Examination of Physical Examination of Physical Examination of the the Knee the Knee KneeKnee--ACLACL Tests --1919 PCL TESTS PCL TESTS Posterior Drawer Test PROBABLY MOST IMPORTANT Posterior Drawer Test CONCEPT IN EXAMINATION ! “The posterior drawer test…., and its accuracy is increased when results Important to identify if there is are combined with other tests…. a PLC injury to the Arcuate (CORROBORATIVE TESTING) complex !
Physical Examination of the KneeKnee-- Physical Examination of Physical Examination of the Anterior Instability Tests KneeKnee--AnteriorAnterior Drawer Test Lachman’s Test (Ritchie/Trillat/Lachman-Trillat) (SEN:63-99)(SP:42- 100)(+LR:2.15-11.3) the Knee Stable Lachman’s Test Drop Leg Lachman Test Modification 4 ACL TESTS Modification 5 Prone Lachman Test Active (no touch) Lachman Test Maximum Quadriceps Lachman Test Active Lachman’s/Drawer Test Anterior Drawer Test (SEN:18-95)(SP:55-100)(+LR:1.6-8.3) Anterior Drawer Test 90-90 Anterior Drawer Sitting Anterior Drawer Test Active Drawer Test Anterior Drawer Test in ER (AMRI) Anterior Drawer Test in IR (ALRI) Pivot-shift (SEN:6-93)(+LR:10.3) First described by Segund in (SEN:18(SEN:18--95)95) Flexion-Rotation Drawer (SP:55(SP:55--100)100) Jerk Test of Hughston (Reverse pivot-shift test) 1879 (+LR:1.6(+LR:1.6--8.3)8.3) Fibular Head Sign
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Physical Examination of Physical Examination Physical Examination the Knee of the Knee of the Knee ACL TESTS ACL TESTS ACL TESTS Anterior Drawer Test Knee --7070°° Anterior Drawer Test It is important to establish the Anterior Drawer Test - limitations starting reference position so we Meniscus can act as “chock blocks” The data suggest that the anterior do not mismis--interpretinterpret the tibial Effusion drawer test becomes translation (false positives with Pain increasingly more sensitive as PCL insufficiencies) Patient comfort the secondary restraintsof (10 mm stepstep--up)up) Only checks the AMB of ACL anterior stability are lost
Physical Examination Physical Examination Physical Examination of the KneeKnee--Lachman’sLachman’s Test of the Knee of the Knee (SEN:63(SEN:63--99)99) ACL TESTS ACL TESTS (SP:42(SP:42--100)100) Anterior Drawer Test Lachman Test (+LR:2.15(+LR:2.15--11.3)11.3) SitiitSensitivity: Acut e i nj uri es: 22% -70% Chronic injuries: 54%-54%- Noulis’ Thesis, 1875 97% Century Under anesthesia: 80%- 80%-91%91% Torg, et.al. AJSM, 1976 Specificity: Acute & Chronic injuries: <3 mm 97% later !!! WNL
Physical Examination of Physical Examination of Physical Examination of the Knee the Knee the Knee ACL TESTS ACL TESTS ACL TESTS Lachman Test Lachman Test Lachman Test Sensitivity: Acute injuries: 80% -99% Clinical interpretation: Chronic injuries: 94%-94%- 99% Visual anterior translation of tibia Several “Hybrid variations”: Under anesthesia: 85%- 85%-99%99% to femur 8 modifications of the Lachman’s Specificity: Acute & Chronic injuries: Proprioceptive anterior translation Test: Under anesthesia: 95% “Soft” or “mushy” end point
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Physical Examination of Physical Examination Physical Examination of the KneeKnee--PivotPivot Shift of the Knee the Knee ACL TESTS ACL TESTS Pivot Shift Test Pivot Shift Test The pivot shift is both a clinical phenomenon that results in a At approximately 2020--3030°°ROM,ROM, complaint of a giving way of the there is a pivoting of the tibia knee and a physical signthat can on the femur (ALRI). (SEN:6(SEN:6--93)93) be elicited on examination of the ITB “slips” over the lateral (+LR:10.3) injured knee. femoral epicondyle.
Physical Examination Physical Examination of Physical Examination of of the Knee the Knee the Knee ACL TESTS ACL TESTS ACL TESTS Pivot Shift Test Pivot Shift Test Pivot Shift Test A positive pivot shift test in a Sensitivity: Acute & Chronic injuries: conscious patient may reflect the 35%35%--98%98% Several modifications: hip patient’s inability to protect the knee, which may suggest that Under anesthesia: 98% positions, knee positions, these patients are less likely to Specificity: Acute & Chronic injuries: tibial rotations respond to non-non-operativeoperative 98% treatment
Physical Examination of the Physical Examination of the Physical Examination of the KneeKnee-- KneeKnee--JerkJerk Test KneeKnee--FlexionFlexion--RotationRotation Drawer Rotary Instability Tests -30- 30
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Physical Examination of the KneeKnee-- Physical Examination of the KneeKnee-- Physical Examination of the KneeKnee-- Anteromedial Rotary Instability Tests Anterolateral Rotary Instability Tests Posteromedial Rotary Instability Tests
Slocum Test with Internal Tibial Slocum Test with Rotation (ALRI) Hughston External Tibial Lateral Pivot Shift Test of Macintosh Postermedial Rotation (AMRI) Active Pivot Shift Test Drawer Test Losee Test Lemaire’s anteromedial Jerk Test of Hughston Jolt Test (T Drawer, Crossover Test of Arnold Posteromedial pivot Y Test) Lemaire’s Jolt Test shift test Dejour Test Nakajima Test Noyes flexion-rotation drawer test Flexion-extension valgus test Martens Test
Physical Examination of the KneeKnee-- Physical Examination of the KneeKnee-- Physical Examination of the Posterolateral Rotary Instability Tests MCL Valgus Stress Tests -7- 7 Medial Stability Tests Pivot Shift Test Jakob Test (Reverse pivot shift maneuver) Valgus stress test at 0° External Rotation Recurvatum Test Valgus stress test at 30° (SEN:78- Jerk Test 100)(SP:49-100)(+LR:.1.8-2.3) Loomer’ s PLRI Test Bousquet external hypermobility test Hht’VlHughston’s Valgus st ress at t0 0° Tibial External Rotation Tests Hughston’s Valgus stress at 30° Hughston Posterolateral Drawer Test Swain Test Dial Test (Tibial External Rotation Test) Dynamic posterior shift test Apley’s Distraction Test with ER Active posterolateral drawer sign Apley’s Distraction Test with ER with DDV Arcuate Spin Test (Davies Dynamic Version) Standing Apprehension Test Frog Leg Maneuver
Physical Examination of Physical Examination of the KneeKnee-- Physical Examination of the Knee MCL Valgus Stress TestTest--00 the Knee VALGUS STRESS TESTS VALGUS STRESS TESTS
00°°Extension: MCL, capsule, Palmer, ActaChir ACL,PCL, PMOL, etc. (MCL-(MCL- Scand Suppl, 1938 57%) 3030°°Flexion:Flexion: MCL (MCL(MCL--78%)78%)
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Physical Examination of the KneeKnee-- Physical Examination of the Physical Examination of the MCL Valgus Stress TestTest--3030 KneeKnee--ApleysApleysDistraction Test KneeKnee--Apley’sApley’s DistractionDistraction--DDVDDV
(SEN:78(SEN:78--100)100) (SP:49(SP:49--100)100) (+LR:1.8(+LR:1.8--2.3)2.3)
AMA Nomenclature - Clinical Pearl Knee Instability Testing MCL Valgus Stress Testing z When performing a valgus stress z Classification of knee instability testing: test, z Grade I : mild sprain z Start by “closinggj the joint” first – z Grade II: moderate sprain z 1+ - 1-5 mm more laxity z To perform the valgus stress test, z 2+ - 6-10 mm more laxity actually begin by moving toward z Grade III: severe sprain varus first to approximate the tibia z 3+- > 10 mm more laxity to the femur
MCL Valgus Stress Test Clinical Pearl – MCL Valgus Stress Testing Clinical Pearl z When performing a valgus stress zMCL Valgus Stress Injury zClosing the joint is test, analoggygous to identifying z Start by “closing the joint” first – the starting reference zThink about a PF position just like when z Reason is to approximate the joint subluxation also as a surfaces so one can palpate the potential additional injury performing a PCL/ACL joint line opening and kinesthetically feel the amount of and a coco--morbiditymorbidity test motion
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Physical Examination of the KneeKnee-- Physical Examination of the Physical Examination of the KneeKnee-- LCL VarusStress Tests -6- 6 KneeKnee--LateralLateral Stability Tests LCL Varus Stress TestTest--00
Varus stress test at 0° Varus stress test at 30° (()()SEN:100)(SP:20) Hughston’s Varus stress at 0° Hughston’s Varus stress at 30° Apley’s Distraction Test with IR Apley’s Distraction Test with IR with DDV (Davies Dynamic Version)
Physical Examination Physical Examination of the KneeKnee-- Physical Examination of of the Knee LCL Varus Stress TestTest--3030 the Knee VARUS STRESS TESTS VARUS STRESS TESTS
00°°Extension: LCL, capsule, Need to be particularly ACL,PCL, PLC, etc. (LCL-(LCL- aware of PLC injuries and 55%) (SEN:100) the potential for rotational 3030°°Flexion: LCL (LCL(LCL--69%)69%) (SP:20) movements of the tibia
Physical Examination of the Physical Examination of the Physical Examination of KneeKnee--MeniscusMeniscus Tests -29- 29 KneeKnee--MeniscusMeniscus Tests the Knee 1) Joint Line Tenderness (SEN:27-93)(SP:13-97)(+LR:1.2-31.0) 2) McMurray’s Test (SEN:14-88)(SP:20-100)(+LR:0.82-9.3) 3) Dynamic McMurray’s Test 4) Apley’s Grinding Test (SEN:13-81)(SP:56-100)(+LR:0.80-5.9) MENISCUS TESTS 5) Apley’s Grinding Test with ER with DDV (Davies Dynamic Version) 6) Apley’s Grinding Test with ER with DDV (Davies Dynamic Version) 7) Bounce Home Test/Forced extension (SEN:36-47)(SP:67-86)(+LR:1.2-2.9) 8) Flexion Block/Forced Flexion (SEN:44-77)(SP:41-68)(+LR:1.0-1.6) 9) Steinman’s I Point Tenderness Displacement Test (SEN:29-86)(SP:83-88)(+LR:3.88-7.17) 10) Steinmann II Sign 11) Boehler Test 12) Payr Test (SEN:54)(SP:44)(+LR:0.96) 13) Axial Pivot-shift test (SEN:71)(SP:83)(+LR:4.2) Hey, Prac tical ob servati ons 14) Dynamic test (SEN:85)(SP:90)(+LR:8.5) 15) Medial-Lateral Grind Test 16) Figure 4 Test (SEN:100)(SP:0) 17) Ege’s Test (SEN: 64-67)(SP:81-90)(+LR:3.5-6.4) in Surgery, 1803, was the 18) Thessaly Test at 20 /Disco Test (SEN:31-92)(SP:40-97)(+LR:1.3-30.0) 19) Thessaly Test at 5 (SEN:27-81)(SP:91-96)(+LR:6.8-16.5) 20) Childress Test/squat/duck waddle (SEN:55-68)(SP:60-67)(+LR:1.7) 21) Finochietto Jumping Sign first to describe the 22) O’Donoghue’s Test 23) Modified Helfet Test 24) Test for retreating or retracting Meniscus 25) Bragard’s Sign “internal derangement of 26) Kromer’s Sign 27) Anderson Medial-Lateral Grind Test 28) Passler Rotational Grind Test 29) Cabot’s Popliteal Sign the knee”
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Physical Examination of the Physical Examination of the KneeKnee-- Physical Examination of the KneeKnee--RecurvatumRecurvatum Test Steinman’s Point Pressure Test KneeKnee--McMc Murray’s Test
(SEN:36(SEN:36--47)47) (SEN:29(SEN:29--86)86) (SEN:14(SEN:14--88)88) (SP:67(SP:67--86)86) (SP:83(SP:83--88)88) (SP:20(SP:20--100)100) (+LR:1.2(+LR:1.2--2.9)2.9) (+LR:3.88(+LR:3.88--7.17)7.17) (+LR:0.82(+LR:0.82--9.3)9.3)
Physical Examination of the Physical Examination of the Physical Examination of KneeKnee--McMurray’sMcMurray’s Dynamic Test KneeKnee--Apley’sApley’s Compression Test the Knee MENISCUS TESTS Apley Grind Test
“Surgeon leans well over the patient and with his whole body weight, compresses the tibia (SEN:13(SEN:13--81)81) downward onto the couch. (SP:56(SP:56--100)100) Again he rotates powerfully….” (+LR:0.80(+LR:0.80--5.9)5.9) OUCH !!!!
Physical Examination of the KneeKnee-- Physical Examination of the Physical Examination Apley’s Compression- Compression-DDVDDV Knee Predictive Value of Clinical Signs in Evaluation of of the Knee Meniscal Pathology; Fowler, et.al. Arthroscopy, Very few tests by themselves are 5:184,1989 absolutely accurate, therefore z No one testis predictive for diagnosis of meniscal tear the “clusters of signs and z Presence of ACL pathology will render test less symptoms” and using the effective constellation of exam findings z Joint line tenderness, pain with forced hyperflexion (Steinman’s Test), and positive and the corroboration of tests Mc Murray’s together provide best predictor are the key to a good of meniscal tear examination and diagnosis
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Physical Examination of the Physical Examination of the Physical Examination of the KneeKnee--PlicaPlicaSyndrome Tests -9- 9 KneeKnee--MiscellaneousMiscellaneous Tests KneeKnee--MiscellaneousMiscellaneous Tests Tests for Osteochondral Lesions Flexibility TestsTests--CrossCross knee Thomas Test Medial Patellar Plica Test Wilson’s test Ober’s Test (SEN:90)(SP:89)(+LR:8.18) Proximal TibiofibularJoint Instability Modified Ober’s Test Medial Plica Shelf Test Fibular Head Translation Test Ely’s test Medial Plica Test Knee Angle Measurements Rotation Valgus Test Patella tendon/ligament length test Q-Angle/Patellofemoral Angle Test Holding Test Tubercle Sulcus Angle (Q-Angle at 90 ) A-Angle Plica/Patellar Stutter Test ITB Syndrome Noble’s Compression Test Daniel’s Quadriceps Neutral Angle Test Hughston’s Plica Test Renne’s Test Bayonet Sign Patellar Bowstring Test Mediopatellar Plica Test (Mital-Hayden Test) Hoffa’s Syndrome Test Functional test for Quadriceps Contusion
Test for knee Extension Contracture (Heel Height Difference)
Functional Testing Algorithm – Summary zCorroboration of Knee -2016 z Sport Specific Testing Competitive tests to implicate z Lower Extremity Functional Athletes And Tests z Functional Hop Tests or rule out z Functional Jump Tests Recreational Conclusions z OKC Isokinetic testing Athletes various injuries z CKC Isokinetic Testing z Sensorimotor System Testing: General Balance/Proprioceptive Orthopaedic or injured Testing Patients z KT 1000/2000 structures z Basic Measurements
Functional Testing Algorithm – Thanks to RUSH Sports Knee -2016 Medicine Symposium z Sport Specific Testing Competitive z Lower Extremity Functional Athletes Tests z Functional Hop Tests z Functional Jump Tests Recreational z OKC Isokinetic testing Athletes Than k You z CKC Isokinetic Testing z Sensorimotor System Testing: General Balance/Proprioceptive Orthopaedic Testing Patients z KT 1000/2000 z Basic Measurements
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