Special tests for knee pathology prove inconclusive

For many years, Physiotherapists have diagnosed knee injuries by way of a well worn assessment process incorporating a subjective examination and a suite of objective tests including passive ligament stress tests, passive accessory and physiological motion testing, active range of motion testing and functional movement testing (e.g squat, jump, hop etc). In recent years debate has raged over the value of specific manual orthopaedic testing within the context of diagnosing specific joint pathology. The debate relates to research that casts doubt over both the inter-rater and intra-rater reliability of many of these objective tests, which in turn casts doubt on the extent to which these tests contribute to Physiotherapists’ diagnostic capabilities.

In an unfortunate but ultimately useful coincidence, a staff member (pictured) at The Good Health Tribune who had been researching this article was struck down by a knee injury. Experienced Physiotherapist and staunch advocate for manual orthopaedic testing, Ralph Testwell, who had been earmarked to provide an opinion for this article was kind enough to offer his services to our injured worker. Our reporter asked Mr Testwell to explain his view on the value of specific orthopaedic tests for the knee joint.

“Well, I think they’re essential, particularly in an acute setting where there’s been a traumatic mechanism of injury. It’s crucial that the patient knows whether they’ve injured the MCL or the medial meniscus, and I can make that judgment by way of an MCL stress test and a McMurrys test”.

We put it to Mr Testwell that an argument has been made that such specificity of diagnosis is not essential for the commencement of appropriate treatment, and that reasonable judgments about suspected specific joint pathology can be garnered from the subjective history, and confirmed via MRI at a later date if indicated.

“Yeah, well I know the type of Physios who push that view and I can assure you they haven’t got a clue what they’re talking about… They’re all always banging on about being less specific, you know, make sure you’re seeing the big picture- the forest for the trees and all that jazz. But I don’t want my patients going to bed wondering if they have a grade two ligament strain when I can assure them it’s only a grade one. I mean, how are they supposed to sleep with that level of uncertainty? My focus is on providing my patients with the highest level of certainty- and I have the skills to do that”

Snapshot of our injured worker kindly assessed by Mr Testwell

“Ok, now let’s take a look at this knee of yours. There’s a quite a large degree of valgus laxity and you’re quite tender over the pes anserine. So I think you may some MCL pathology and a little bursitis on the medial aspect of your knee. Hmm… McMurry’s seems negative… Let’s see how the pivot shift feels…”