Special tests Flashcards
General considerations for ligament testing
Standerdise start position Test unaffected leg first in order to test the normal laxity of that patient's ligaments before you start Try and relax the patient Reduce muscle spasm What is a positive test Evidence ?
ACL research
Benjaminse 2006
Meta analysis of papers looking at the accuracy of clinical tests for the ACL
Lachmans: most valid test for ACL ruptures with high sensitivity and specificity
Anterior drawer shows good sensitivity and specificity in chronic ruptures but not acute
Lachmans
Said to be most valid test for ACL ruptures
Sensitivity:
Specificity: 94%
Sensitivity: 85%
Knee flexed to 20-30 degrees
One hand on femur to block
Grasp tibia from medial side and pull forwards
End feel and laxity compared to other side
A positive test is indicated by a soft end-feel and excessive motion. The end-feel, or lack thereof, is the key.
can be graded:
Grade 1
1-5 mm
Grade 2
5-10 mm
Grade 3
> 10 mm
Anterior drawer
Better for chronic ruptures Tests the antero medial band Knee in 80 degrees of flexion Sensitivity: 92% Specificity: 91%
Lever test
Lever test - place fist under calf
Other hand pushes down on the quads
If ACL is in tact - Lower leg will lift
If positive for ACL rupture - Lower leg will not lift
Early studies showed very high specificity/sensitivity but this has not been replicated since
Better in the acute setting
Pivot shift
Decide not to use due to test being more accurate when done on patient’s who are anaesthetised
More complex handling to get correct
Low specificity
PCL
Combine posterior sag and posterior drawer for higher sensitivity and specificity
Active quadriceps test - varied spec and sensitivity in research
Posterior sag
Knee flexed up to 90 degrees Put knee on a stool Looks for difference between L and R IF used with posterior drawer: Sensitivity: 90% Specificity: 99%
Posterior drawer
Supine Knee flexed to 90 degrees A->P push on tibia IF used with posterior sag: Sensitivity: 90% Specificity: 99%
Dial test
Prone
Use forearms to rotate feet out
LR of tibia
30 degrees flex = PCL+PLC
90 degrees flex = PCL
More than 10 degrees difference in ROM is a positive test
No data on specificity/sensitivity so questionable clinical utility
MCL - VALGUS stress test
In this test you are aiming to open up the medial side of the joint by applying an angulating abduction force. With the patient supine, the clinician palpates the medial joint line of the knee and applies a valgus force.
The test needs to be performed in both 20-30° of flexion and full extension and both the amount of give and end feel considered.
The test is positive when there is excess give into valgus (left-right differences of greater than 3° is often classed as pathological (Magee, 2014).
If the test is positive in slight flexion but negative in full extension then an isolated tear of the medial collateral ligament (MCL) (superficial and / or deep fibres) can be suspected.
If the test is positive in extension this is suggestive of both a complete MCL tear and possible involvement of the posterior oblique ligament and posterior medial capsule, including semimembranosus tendon. If there is marked opening then a tear of the posterior cruciate ligament (PCL) and/or anterior cruciate ligament (ACL) needs to be considered.
Technique = Supine
Hand medially at ankle
Block femur from moving on the outside
20-30 degrees = isolated MCL
0= consider capsule, posterior oblique ligament and possibly ACL/PCL
86%-96% sensitivity but specificity not reported
LCL - varus stress test
LCL
Sit on coach and have patient’s leg over you
Do in full extension and 20-30 degrees flexion
Palpate lateral joint line
fix femur medially
Hold ankle laterally
pull foot in towards you
20 degrees +ve = LCL isolated
+ve at 20 and in full ext = LCL, posteral lateral capsule, ACL, PCL
Slocum’s test - ACL/MCL/LCL
If a patient has a positive anterior drawer in full extension the MCL is likely to be involved
In order to check do the anterior drawer with the tibia ER to tighten up the MCL and if it doesn’t change - likely ACL and MCL together
If it has a reduction in laxity MCL likely to be intact
Medial meniscus
McMurrays: Full flex-90, ER and extension - turn foot out
Medial joint line palpation: varies in literature to how important this is with wide variety of sensitivity/specificity recorded
Use bigger picture with subjective Hx to back it up
Lateral meniscus
McMurrays: Full ext flex 90, IR - turn foot in and extend
Joint line palpation: varies in literature to how important this is with wide variety of sensitivity/specificity recorded
Use bigger picture with subjective Hx to back it up
