Msc Manual Therapy
The Knee
OBJECTIVE ASSESSMENT:
HYPOTHESIS TESTING.
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
 Repeat
 Extension
 Sustain
 Medial rotation through
 Combine movements
range
 Lateral rotation through
range
 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
Test
Sensitivity
Specificity
McMurray’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).
ACL tests
Lachmans
 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
Anterior Drawer Test
 (+) 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
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????
MCL
Valgus stress test
 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
LCL
Varus Stress Test
 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
PLC
Reverse Lachmans
Dial Test
 Prone, femur fixed.
 Prone, knees flexed to
 Ant drawer to end
90˚.
 Externally rotate feet.
 +ve if effected foot
moves ?15˚ more.
point.
 +ve tib tuberosity and
fib head move lat.
Valgus Stress Test
Hyperextension
 Full extension.
 In standing/walking
 20˚ flex.
will have ext/lat thrust.
 Prone heels over bed:
+ve if heel dropped.
 If increase in
movement think PLC.
Patellofemoral Tests
Clarke’s (grind) test
 No evidence.
 Many false positives.
 +ve if reproduces pain
or unable to hold
contraction.
Compression test
Apprehension test
 Force patella into
 Flex knee to 20-30˚.
trochlea.
 Monitor pain response.
 Laterally displace
patella.
Accessrory Movements: neutral/through range
Tibio femoral
Tibio fibular
 Tibia:
 Fibular head:
 Femur:
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?