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Orthopaedic tests

1. McMurray's Test - Medial Meniscus tear
2. McMurray's Test - Lateral Meniscus tear
3. Apley's Compression Test - Meniscus Tear
4. Anterior Drawer Test (ACL)
5. Posterior Drawer Test (PCL)
6. Anterior Lachman Test (ACL)
7. Posterior Lachman Test (PCL)

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Surface markings

Medial Aspect
1. Tibial tuberosity
2. Patellar tendon
When you reach the joint gap, push downward you will feel the sharp ridge of 
3. Tibial plateau
4. Medial femoral condyle
5. Medial femoral epicondyle
6. Adductor tubercle
Rotate the tibia medially, and you will feel the
7. medial meniscus & coronary ligament.
Move inferiorly, laterally toward tibial tuberosity; you should feel
8. Pes anserine insertion ( Tendons of sartorius, gracilis, Semitendinosus)
Lateral Aspect
1. Tibial tuberosity
2. Patellar tendon
3. Tibia plateau
4. Lateral condyle of the femur
5. Epicondyle of femur
Come back to the joint gap, externally rotate the tibia, and you will feel
6. the lateral meniscus.
Move inferiorly, draw a big circle, and you will find the
7. fibula head
Go inferiorly around the neck of the fibula, and you will find
8. common peroneal nerve
 

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Manipulation

1. PCL ligament adjustment
2. ACL ligament adjustment.  video
3. Non-specific thrust for adhesions in the knee joint
4. Adductor stretch (done in the rehabilitation stage of treatment)
5. Figure 8 (OA patients) supine
6. Figure 8 (OA patients) sitting
7. Medial meniscus adjustment (McMurray's)
8. Medial meniscus adjustment (supine)
Fibula head
1. Anterior thrust supine
2. Anterior thrust side lying
3. Posterior thrust side lying

 

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1. Chondramalacia Patella
2. Osgood Schalatters Disease
3. Osteochondritis Dissicans
4. Painful Arc
5. Cystic Swelling About The Knee
6. Chronic Knee Sprain "Gammy Knee"
7. Popliteal and semimembranosus tendinitis
8. Osteoarthritis

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Orthopaedic Tests

McMurray Test

Purpose:

 

Determine the integrity of the meniscus. Diagnose a meniscus tear.

 

Instructions:

 

1. With the patient lying flat, the knee is first fully flexed; the foot is held by grasping the heel.

 

 

2. The leg is rotated on the thigh with the knee still in full flexion.

 

 

3. By altering the position of flexion, the whole posterior segment of the cartilage can be examined from the middle to posterior attachment.

 

 

4. Bring the leg from its position of acute flexion to a right angle while the foot is retained first in full internal rotation and then in full external rotation.

 

 

5. When the click occurs, the patient is able to state that the sensation is the same they experienced when the knee gave way previously.

Apley's Compression Test

Purpose:

 

Determine the integrity of the meniscus. Diagnose a meniscus tear.

 

Instructions:

 

1. The patient is prone and the examiner grasps one foot in each hand and externally rotates the tibia as far as possible, and then flexes both knees together to their limit.

 

 

2. The feet are then rotated inward and knees extended, and the examiner applies his left knee to the back of the patient's thigh.

 

 

3. The foot is grasped in both hands, the knee is bent to a right angle, and powerful external rotation is applied.

 

 

4. The examiner leans over the patient and compresses the tibia downward. Again he rotates powerfully, and, if addition of compression produces an increase in pain, this grinding test is positive.

Anterior Drawer Test

Purpose:

 

Determine the integrity of the Anterior Cruciate Ligament (ACL) - full or partial tear. Anterior plane instability.

 

Instructions:

 

1. The knee is flexed between 60 and 90 degrees with the foot resting on the exam table.

 

 

2. The examiner puts both hands behind the tibia and attempts to displace the tibia anteriorly while the foot remains resting on the table.

 

 

3. Increased tibial displacement with the foot in neutral indicates a positive test which is graded by severity:
Grade 1 = 5 mm
Grade II = 5-10mm
Grade III = > 10 mm.

 

 

4. The test is then repeated with the tibia in 15 degrees of external rotation and then in 30 degrees of internal rotation to determine integrity of posterolateral and posteromedial corners.

Posterior Drawer Test

Purpose:

 

Determine the integrity of the Posterior Cruciate Ligament (ACL) - full or partial tear. Posterior plane instability.

 

Instructions:

 

1. The knee is flexed between 60 and 90 degrees with the foot resting on the exam table.

 

 

2. The examiner puts both hands behind the tibia and the thumbs anteriorly on the tibial plateau in order to palpate the tibia-femur step-off.

 

 

3.Grades:
a) Grade 1 = increased posterior tibial displacement but tibia not flush with femoral condyles with knee flexed to 90 degrees
b) Grade II = Anterior tibia is flush with femoral condyles.
c) Grade III = Anterior tibia is subluxed posterior to the anterior surface of the femoral condyles.

Anterior Lachman Test

Purpose:

 

Determine the integrity of the Anterior Cruciate Ligament (ACL) - full or partial tear. Anterior plane instability.

 

Instructions:

 

1. The patient is supine and the involved limb is on the side of the examiner.

 

 

2. The knee joint is placed into 20-30 degrees of knee flexion.

 

 

3. One hand of the examiner is placed on the femur for stabilization, while the other hand is applied to the posteromedial aspect of the proximal tibia in an attempt to translate it anteriorly.

 

 

4. Any subluxation anteriorly compared to the uninjured knee demonstrates a positive test.

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Conditions

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Osteoarthritis

  1. Common in older people.

  2. 14-34% of those 45+.

  3. Symptoms: pain, stiffness, swelling.

  4. Risks: overweight, age 50+, female, overwork, previous knee issues, family history.

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Patellar chondromalacia

  1. Most common cause of runners' knee pain.

  2. Softening of the patellar cartilage.

  3. Due to repeated microtrauma to the patella.

  4. Common in females aged 15-35.

  5. Causes: foot, tibia, or hip issues, muscle imbalances, connective tissue problems.

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Osteochondritis dissecans

  1. Common condition affecting cartilage and bone.

  2. Mostly in men in their twenties.

  3. More common in men (2:1 ratio).

  4. Affects both kids and adults.

  5. Causes 50% of knee loose bodies.

  6. Mainly hits the inner thigh bone in 85% of cases.

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Patellar tendonitis

  1. Inflammation of the patellar or quadriceps tendon.

  2. Common in teenage boys, especially athletes in jumping sports.

  3. Linked to foot pronation, patellar misalignment, or high patella.

  4. Symptoms: front knee pain, swelling, thickening, or nodules.

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Iliotibial band syndrome

  1. Common cause of lateral knee pain.

  2. Often in those doing repetitive knee flexions, like runners or cyclists.

  3. Caused by friction between the iliotibial band and femoral epicondyle during knee movement.

  4. Accounts for 12% of running-related overuse injuries.

  5. Risk factors: overpronation, genum varum, leg length difference, and myofascial restriction.

    Genum varum also known as bow-leggedness, is a condition where the knees are abnormally positioned outward, resulting in a gap between the lower legs when the feet are together. In individuals with genum varum, the knees are positioned away from each other while the ankles touch. This can be caused by various factors such as genetic predisposition, nutritional deficiencies, or certain medical conditions affecting bone development. In some cases, it may be a normal variation during early childhood and typically improves as a child grows older. However, persistent or severe cases may require medical attention or intervention.

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Red Flag Knee Conditions

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Knee fractures

  1. History of recent trauma like an injury or fall.

  2. Pain, bruising, or swelling in the knee.

  3. Numbness, tingling, or pins and needles feeling.

  4. Trouble bending the knee.

  5. Inability to walk or put weight on the affected leg.

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Compartment syndrome

  1. History of trauma.

  2. Severe, persistent pain and hardness in the front shin area.

  3. Pain increases with stretching of affected muscles.

  4. Pain during dorsiflexion of toes.

  5. Swelling, tightness, and bruising in the affected compartment.

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Septic Arthritis

  1. Fever and chills.

  2. Recent bacterial infection, surgery, or injection.

  3. Severe chest pain.

  4. Feeling unwell, fatigued, or loss of appetite (malaise).

  5. Having an immunosuppressive disorder.

  6. Red, swollen joint without a history of trauma.

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Deep vein thrombosis

  1. History of recent surgery.

  2. Calf pain.

  3. Redness of the skin.

  4. Swelling and tenderness in the affected leg.

  5. Pain worsens with walking or standing, and improves with elevation and rest.

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Extensor mechanism disruption

  1. Ruptured quadriceps or patella tendon.

  2. Changed position of the patella (superior translation).

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Cancer

  1. Persistent, unrelenting pain.

  2. History of previous cancer.

  3. Atypical symptoms with no trauma history.

  4. Systemic symptoms like fever, chills, malaise, and weakness.

  5. Unexplained weight loss.

  6. Suspected malignancy or unexplained deformity, mass, or swelling.

Exam Type Questions

1. **“Screw Home” Principle:**
   - *Question:* Discuss the “screw home” principle with regard to knee function.
   - *Answer:* The "screw home" mechanism refers to the rotation that occurs in the knee joint during the last 20-30 degrees of knee extension. As the knee extends, the tibia externally rotates on the femur due to the shape and orientation of the medial and lateral condyles of the femur. This rotation helps to lock the knee in a stable position, allowing for better weight-bearing support.

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2. **McMurray Test:**
   - *Question:* What does the McMurray test check for?
   - *Answer:* The McMurray test is performed to check for meniscal injuries in the knee. The test involves manipulating the knee joint through specific ranges of motion while listening for or feeling clicks or pops, which may indicate a tear or damage to the meniscus.

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3. **Dorsiflexion before Compression:**
   - *Question:* Why is it important to dorsiflex the patient's foot before commencing compression?
   - *Answer:* Dorsiflexing the patient's foot before compression is important to relax the calf muscles and the gastrocnemius specifically. This action helps to isolate the knee joint and minimizes the influence of other muscles during the compression test. It ensures a more accurate evaluation of the knee's stability and the potential presence of certain injuries or conditions.

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4. **Mechanics of Knee Injuries (ACL and PCL):**
   - *Question:* Discuss briefly how the mechanics of a knee injury outline an ACL and a PCL injury and how these would help you reach a prognosis BEFORE you examine the knee.
   - *Answer:* An ACL injury often occurs during a sudden stop or change in direction, causing the ligament to stretch or tear. A PCL injury is often the result of a direct impact on the front of the knee. Prognosis is influenced by the mechanism, severity, and associated injuries, which can be considered before a physical examination.

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5. What does the Lachman test do that the A.C.L. / P.C.L. drawer test doesn’t do?

  • Answer: The Lachman test is more accurate than the A.C.L./P.C.L. drawer test. It provides a more reliable evaluation of anterior cruciate ligament integrity, as it is less influenced by hamstring tightness, reducing the likelihood of false negatives.

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6. **Adjusting ACL with Knee Pointed Opposite Shoulder:**
   - *Question:* Why, when adjusting the A.C.L., is the patient's knee pointed towards the opposite shoulder?
   - *Answer:* When adjusting the A.C.L., the patient's knee is pointed towards the opposite shoulder to create tension in the ligament. This tension allows for a more accurate assessment of the ligament's integrity and facilitates a controlled adjustment. The specific positioning helps the therapist apply targeted force during the adjustment, ensuring that the manipulation addresses the A.C.L.'s origin and insertion points appropriately.

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7. **Medial Meniscus Adjustment:**
   - *Question:* Outline what you consider 4 important points the therapist must be aware of when doing a medial meniscus adjustment.
   - *Answer:*
     - a. Careful patient positioning to isolate the meniscus.
     - b. Precise localization of the meniscus for targeted adjustments.
     - c. Gradual and controlled force application to avoid excessive stress.
     - d. Post-adjustment assessment to ensure stability and function.

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8. **Fibula Head Adjustment Signs/Symptoms:**
   - *Question:* Give 3 signs/symptoms that would lead you to believe during your examination that a fibula head may need an adjustment.
   - *Answer:*
     - a. Pain or tenderness around the fibula head.
     - b. Limited range of motion in ankle dorsiflexion or eversion.
     - c. Altered gait or weight-bearing patterns.

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9. **Osgood Schlatters vs. Osteochondritis Dissicans:**
   - *Question:* List 5 differences between Osgood Schlatters disease and osteochondritis dissicans.
   - *Answer:*
     

  1. Pathology and Location:

    • Osgood Schlatters: Involves inflammation of the patellar ligament and the tibial tuberosity (bump on the upper part of the shinbone).

    • Osteochondritis Dissecans: Affects the joint surface and involves the separation of a piece of cartilage and underlying bone within a joint.

  2. Age of Onset:

    • Osgood Schlatters: Commonly occurs in adolescents during periods of rapid growth, especially during puberty.

    • Osteochondritis Dissecans: This can occur in adolescents but is also seen in young adults.

  3. Symptoms:

    • Osgood Schlatters: The main symptoms include pain, swelling, and tenderness over the tibial tuberosity.

    • Osteochondritis Dissecans: Symptoms may include joint pain, stiffness, and possible locking or catching sensations.

  4. Affected Area:

    • Osgood Schlatters: Primarily affects the front of the knee where the patellar ligament attaches to the tibial tuberosity.

    • Osteochondritis Dissecans: Can affect various joints but is commonly found in the knee.

  5. Aetiology:

    • Osgood Schlatters: Often related to overuse or repetitive stress on the knee during physical activities.

    • Osteochondritis Dissecans: The exact cause is not always clear but may involve repetitive trauma, genetics, or vascular issues affecting the bone.

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10. **Patellar Tap in Knee Examination:**
    - *Question:* What is the patellar tap used for in a knee examination?
    - *Answer:* The patellar tap is used to assess the presence of excess fluid in the knee joint (effusion) by tapping the patella with the knee in a slightly flexed position. If there is a noticeable "give" or floating sensation, it may indicate the presence of fluid.

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11. **Importance of General Health in Case History:**
    - *Question:* Why, when taking a case history, is it important to ask the patient about their general health?
    - *Answer:* When taking a case history, asking about the patient's general health is crucial for several reasons:

  1. Overall Context:

    • Example: Knowing about general health provides a broader context for understanding the patient's well-being, potential risk factors, and lifestyle factors that could influence their musculoskeletal condition.

  2. Underlying Conditions:

    • Example: Certain general health conditions, such as diabetes or cardiovascular issues, may have implications for the choice of treatment modalities or the potential impact on the patient's response to physical therapy.

  3. Medication and Allergies:

    • Example: Information about medications and allergies is vital for ensuring that any proposed treatment plans or interventions do not interact adversely with existing medications or trigger allergic reactions.

  4. Risk Assessment:

    • Example: General health status helps in assessing the overall risk associated with certain physical activities, exercises, or manual therapies, allowing the therapist to tailor interventions to the patient's specific health needs.

  5. Holistic Approach:

    • Example: Taking a holistic approach to patient care involves considering not only the specific musculoskeletal issue but also understanding how the patient's overall health may contribute to or affect their condition.

In summary, asking about general health during a case history provides a comprehensive understanding of the patient's health status, enabling the therapist to create a personalized and effective treatment plan while considering potential interactions or risks associated with their overall well-being.

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