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Flashcards in Knee Deck (10)
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2 test for ACL?

Pivot shift - sensitivity and specificity are respectively 0.32 and 0.98

The patient lies supine with legs relaxed. The examiner grasps the heel of the involved leg with examiners opposite hand placed laterally on the proximal tibia just distal to the knee.

The examiner then applies a valgus stress and an axial load while internally rotating the tibia as the knee is moved into flexion from a fully extended position.

A positive test is indicated by subluxation of the tibia while the femur rotates externally followed by a reduction of the tibia at 30-40 degrees of flexion.

Lachmanns - Lie the patient supine on the bed. Place the patient's knee in about 20-30 degrees flexion.

According to Bates' Guide to Physical Examination, the leg should also be externally rotated slightly.

The examiner should place one hand behind the tibia and the other on the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity. On pulling the tibia anteriorly, an intact ACL should prevent forward translational movement of the tibia on the femur ("firm end-feel").

Katz and Fingeroth [3] reported that the Lachman test has a diagnostic accuracy of acute ACL ruptures (within 2 weeks of examination) of 77.7% sensitivity and >95% specificity. This study reported the diagnostic accuracy of subacute/chronic ACL ruptures (more than 2 weeks before examination) as having an 84.6% sensitivity and >95% specificity.


Tests for LCL?

Adduction (varus) stress test

Purpose: The varus stress test shows a lateral joint line gap.

Performance: A varus stress test is performed by stabilizing the femur and palpating the lateral joint line. The other hand provides a varus stress to the ankle. The test is performed at 0° and 20-30°, so the knee joint is in the closed packed position. The physiotherapist stabilize the knee with one hand, while the other hand adducts the ankle.[10]

Interpretation: If the knee joint adducts greater than normal (compared to the unaffected leg), the test is positive. This an indication of a LCL tear.

If the varus stress test is positive at 20°, but negative at 0°, only the LCL is torn. A positive result at both 0° and 20° indicate cruciate ligament involvement.[13]

Dial Test -
The test can be clinically valuable when:

Three posterolateral structures (Popliteus tendon, Popliteofibular ligament, Lateral collateral ligament) are injured.
There is combined injury to the PCL and two other posterolateral structures.

The clinician flexs the patient knees to 30° and places both hands on the feet of the patient, cupping his heels.

A maximal external rotation force is then applied, and the foot-thigh angle is measured and compared with the other side.

The knees are then flexed to 90°, and again an external rotation force is applied and the foot-thigh angle is measured again

The test is positive when there is more than 10° of external rotation in the injured knee compared to the uninjured knee.

Because of the difficulty in measuring the external rotation angle, Magee describes the following method of evaluation in his book [8] : If the tibia rotates less at 90° than at 30°, an isolated posterolateral (popliteus corner) injury is more likely. If the knee rotates more at 90°, injury to both the popliteus corner and posterior cruciate ligament is more likely.


Tests for Meniscal tear?

From a position of maximal flexion, extend the knee with internal rotation (IR) of the tibia and a VARUS stress, then return to maximal flexion and extend the knee with external rotation (ER) of the tibia and a VALGUS stress.[1][2][3] The IR of the tibia followed by extension, the examiner can test the entire posterior horn to the middle segment of the meniscus. The anterior portion of the meniscus is not easily tested because the pressure to that part of the meniscus is not as great.

IR of the tibia + Varus stress = lateral meniscus

ER of the tibia + Valgus stress = medial meniscus

Positive findings: Pain, snapping, audible clicking or locking can indicate a compromised meniscus.


Thessaly test?

For meniscal tear:
The test is performed at 5° and 20° of flexion. The examiner supports the patient by holding his or her outstretched hands while the patient stands flatfooted on the floor. The patient then rotates his or her knee and body, internally and externally, three times, keeping the knee in slight fiexion (5°). The same procedure is then carried out with the knee flexed at 20°. The test is always performed first on the normal knee so that the patient may be trained, especially with regard to how to keep the knee in 5° and then in 20° of flexion.


Steinman Test

The patient is sitting on the edge of the table, with the knee hanging over at 90 degrees of flexion, Or the patient is lying on the bed supine with the examiner holding the knee at 90 degrees of flexion.
The tibia is rotated laterally then medially.
The test is positive if lateral pain is elicited on medial rotation and medial pain is elicited on lateral rotation.
The test is repeated in various degrees of knee flexion.

Steinman part 2 or Steinman tenderness displacement test:

This test is specifically to differentiate meniscal pathology from injury as the tenderness do not move in case of pathology while flexion and extension.

Joint line tenderness is elicited.
The knee is flexed and joint line is palpated. A positive test is indicated if the tenderness moves posteriorly with increasing flexion.
The knee is extended and joint line palpated again. A positive test is indicated if the tenderness moves anteriorly when the knee is extended.
The test is repeated in various degrees of flexion and extension.


Apley's Test

Appley's grinding test involves placing the patient in the prone position with the knee flexed to 90 degrees[7]. The patient's thigh is then rooted to the examining table with the examiner's knee. The examiner laterally and medially rotates the tibia, combined first with distraction, while noting any excessive movement, restriction or discomfort. The process is then repeated using compression instead of distraction[3]. If rotation plus distraction is more painful or shows increased rotation relative to the normal side, the lesion is most likely to be ligamentous[3]. If the rotation plus compression is more painful or shows decreased rotation relative to the normal side, the lesion is most likely to be a meniscus injury[3].


Diagnosis- best two tests?

According to Akseki et al. (B) the test (eges) correlated well to arthroscopic findings with a 0,341 kappa score. Akseki et al. compared diagnostic values of the Ege’s test with McMurray’s test and Joint line tenderness. There were no statistically significant differences found between the three tests in detecting a meniscus tear ( p > 0,05). However, for medial meniscus tears, Ege’s test scored better for accuracy, sensitivity, and specificity (respectively, 0,71, 0,67 and 0,81). For lateral meniscus tears Ege's test gave results superior to the others: 0,84 accuracy, 0,64 sensitivity and 0,90 specificity. Ege’s test is more specific than sensitive.

Looking at the different types of Meniscal tears, Akseki et al. found that degenerative tears of the medial menisci were missed in 66% (8 of 12!). Medial meniscal tears were diagnosed correctly with Ege’s test in 84% of cases, compared to only 61% with McMurray’s test. Similarly, Ege’s test was better at diagnosing longitudinal and bucket-handle medial meniscal tears.

Clinical Bottom Line
Two standard tests for a torn meniscus are McMurray's test and joint line tenderness (JLT). McMurray's test is done with the patient lying down. Ege's test is not possible to perform in every patient with a meniscal injury because of the weight-bearing requirements. This test must be performed keeping in view the balance and pain of the patient.


Meniscal anatomy -

There are three ligaments which attach to the meniscus. The transverse (inter-meniscal) ligament is anterior and connects the medial and lateral meniscus. The coronary ligaments connect the meniscus peripherally. The meniscofemoral ligament connects the meniscus to the posterior cruciate ligament (PCL).[4] The menisco-femoral ligament originates from the posterior horn of the lateral meniscus. The meniscus receives blood supply from the medial inferior genicular artery and the lateral inferior genicular artery.

As mentioned earlier, the meniscus is known to have a poor blood supply, especially in the central region which receives its nutrition through diffusion. The cartilage structure of the meniscus acts as a cushion or shock absorber for the knee joint. There are several types of potential tears of the meniscus. These include flap tear, radial tear, horizontal cleavage, bucket handle tear, longitudinal tear, and degenerative tear


Joint Line tenderness (meniscal tear)

The tibiofemoral joint line is palpated to evaluate the maximal sensitivity of the joint line, this means that the palpated point from the joint line gives discomfort and is more tender than the unaffected leg at the same anatomic location.

The knee needs to be flexed in 90°. The border of the joint line at the sides of the patellar ligament and the soft border between the highness of the femur above and below the tibia should be identified. The joint line palpation of the knee starts from the medial border of the patellar ligament towards the posterior aspect of the knee. Beginning at the lateral border of the patellar ligament, the lateral joint line was palpated in a similar way along the joint line in the posterior direction. The medial and lateral joint lines have to be palpated separately. The borders of the tibial plateau and the femoral condyles were palpated to affirm the presence of isolated posterior/medial joint line tenderness. The borders of the patella will not be palpated for any tenderness.

The test is positive if the patient cannot tolerate the pain during the palpation.


Moving Patellar Apprehension Test

This is a test that is designed for the clinical identification of lateral patellar instability.

The moving patellar apprehension test is performed in two parts. Part 1 is a provocation oriented test. The examiner places the knee to be examined into full extension. A lateral force is applied to the patella with the examiner's thumb. The examiner then moves the knee from full extension to 90 deg of flexion and then returning to full extension while maintaining the laterally applied force on the patella.

The second aspect of the test (Part 2) consists of a symptom alleviation manoeuver. The examiner repeats the part 1 of the test with a medially applied force on the patella. The examiner places the knee to be examined into full extension. A medial force is applied to the patella with the examiner's index finger. The examiner then moves the knee from full extension to 90 deg of flexion and then returning to full extension while maintaining the medially applied force on the patella.

A positive test consists of orally expressed apprehension or an apprehensive quadriceps recruitment on the provocation test (part 1), and alleviation of these symptoms with normal ROM within the test ROM in part 2 of the test.