msc manual therapy the knee
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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OBJECTIVE ASSESSMENT:HYPOTHESIS TESTING.
Msc Manual TherapyThe Knee
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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.
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Functional test
GaitSquatSingle leg dipStep upStep downKneelHopFunctional activity relevant to agg and ease.Differential tests
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Active Movements
FlexionExtensionMedial rotation
through rangeLateral rotation
through range
RepeatSustainCombine movementsSpeed alterationDifferentiate
arthrogenic, myogenic, neurogenic.
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Passive Movements
FlexionExtensionMedial rotationLateral rotationF/Ab and F|Ad quadrantE/Ab and E/Ad quadrantOverpressureSustained
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Muscle function
IsometricIsotonicThrough range strengthPNFFlexibilityCore stability
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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).
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Summary of sensitivity and specificity
Test Sensitivity SpecificityMcMurray’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).
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Lachmans
ACL tests
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
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(+) 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
Anterior Drawer Test
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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
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Sensitivity and specificity
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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
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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????
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Valgus stress test
MCL
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
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Varus Stress Test
LCL
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
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Reverse Lachmans Dial Test
Prone, femur fixed.Ant drawer to end
point.+ve tib tuberosity
and fib head move lat.
Prone, knees flexed to 90˚.
Externally rotate feet.
+ve if effected foot moves ?15˚ more.
PLC
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Valgus Stress Test Hyperextension
Full extension.20˚ flex.If increase in
movement think PLC.
In standing/walking will have ext/lat thrust.
Prone heels over bed: +ve if heel dropped.
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Clarke’s (grind) test
No evidence.Many false
positives.+ve if reproduces
pain or unable to hold contraction.
Patellofemoral Tests
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Compression test Apprehension test
Force patella into trochlea.
Monitor pain response.
Flex knee to 20-30˚.Laterally displace
patella.
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Tibio femoral Tibio fibular
Tibia:
Femur:
Fibular head:
Accessrory Movements: neutral/through range
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Patellofemoral
Round the clockRotation
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Other joints/structures
LumbarThoracicSIJHipFoot and ankleNeural: PKB +/- slump, SLR +/- peroneal
nerve bias
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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?