Apley Grind Test


Article Author:
Darin Agresti


Article Editor:
Rebecca Jeanmonod


Editors In Chief:
Sisira Reddy
Joseph Nahas
CHOKKALINGAM SIVA


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Avais Raja
Orawan Chaigasame
Khalid Alsayouri
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Radia Jamil
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Saad Nazir
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Hassam Zulfiqar
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Hussain Sajjad
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Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
4/8/2019 11:17:57 PM

Introduction

Apley Grind test (Apley Compression test) is a maneuver that is performed to evaluate for meniscus injury. This test is named after the British orthopedic surgeon, Dr. Alan Graham Apley. Usually, it is conducted in conjunction with the Apley Distraction test. Meniscal injuries are very common and are associated with significant pain and morbidity. It is a common reason for missed time from school, sports, and work. Meniscal injuries are very uncommon in children younger than ten years old. Males are afflicted more commonly than females, and this is assumed to be related to males engaging in more activities that create rotational injuries, for example, contact sports. No race or ethnicity is more prone to meniscal injury. Prompt diagnosis of these injuries with the proper physical exam, provocative tests such as Apley Grind test and Apley Distraction test, as well as advanced imaging such as MRI (magnetic resonance imaging), is essential to ensure appropriate treatment and a positive outcome for patients.

Anatomy

The meniscus is a C-shaped cartilage that acts as a cushion between the proximal tibia and the distal femur to make up the knee joint.  The average width is 10 mm to 12 mm, and the average thickness is 4 mm to 5 mm. The meniscus is made of fibroelastic cartilage. It is an interlacing network of collagen, proteoglycan, glycoproteins, and cellular elements, and is about 70% water. Three ligaments attach to the meniscus. The transverse (intermeniscal) 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) and has two components: the Humphrey ligament anteriorly, and the ligament of Wrisberg posteriorly. The meniscofemoral ligament originates from the posterior horn of the lateral meniscus. The meniscus is supplied blood from the medial inferior genicular artery and the lateral inferior genicular artery. The meniscus is known to have a very poor blood supply, especially the central portion which gets most of 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.[1]

Indications

An injury to the meniscus should be suspected when a patient presents with knee pain, particularly after a twisting type injury when the foot is planted on the ground. This injury can happen with or without an external force applied to the knee. Usually, pain is located along the knee joint line. Common complaints are pain and mechanical complaints such as clicking, catching, locking, or inability to fully extend the knee. Commonly, these injuries occur in conjunction with ligamentous injuries. When an external force is applied to the lateral knee, it can result in the "unhappy triad." This group of injuries encompasses damage to the medial meniscus or lateral meniscus with concomitate injuries to anterior cruciate ligament (ACL) and the medial collateral ligament (MCL). When performing a physical examination, joint line tenderness, joint effusion, and impaired range of motion are common findings.[2]

Contraindications

Apley’s Grind test should not be performed on patients with gross deformities of the knee. In the setting of major trauma where the knee is deformed with obvious fracture or dislocation, Apley's grind and distraction tests, as well as other provocative tests should be deferred until imaging techniques are performed. Special consideration and technique adjustments should take place for patients with previous amputations.

Equipment

There is no special equipment required to perform this test. Only a standard exam table is needed.

Personnel

No extra personnel are required to perform this test. Only the provider and the patient are required.

Preparation

Apley's grind test is performed with the patient in a standard examination gown and laying in the prone position on the examination table.

Technique

With the patient in the prone position, the knee that is being tested is flexed to 90 degrees while the other leg is fulling extended resting on the exam table. The examiner should apply a downward axial loading force to compress on the patient’s knee. This should be performed by compressing down on the sole while using the other hand to hold down the posterior thigh for stabilization. Internal and external rotation should be applied with compression. If there is pain or restriction with compression and internal or external rotation, this is a positive test. If the pain is experienced over the medial aspect of the knee, this is indicative of a medial meniscus injury. Alternatively, if the pain is experienced over the lateral aspect of the knee, this is indicative of a lateral meniscus injury. Commonly this is performed with Apley’s Distraction test which tests for ligamentous injury rather than meniscal injury. In the same prone position, the examiner will now pull up on the patient’s affected leg instead of providing a loading force downward. This places a strain on the ligaments of the knee. A positive result is when the patient experiences pain. Pain with the distraction of the knee greatly decreases the likelihood of meniscal pathology. By nature of the distraction force, the force applied to the meniscus is reduced considerably.[3][4]

Complications

A complication of the Apley's grind test is a local pain in the knee, but this is necessary to elicit, as that indicates a positive test. As stated in the contraindications section, this test should not be performed on a patient with gross deformity of the knee after major trauma. More serious complications can arise such as worsening of fractures or possibly converting a closed fracture to an open fracture.

Clinical Significance

Diagnosis of a meniscal injury by physical exam and provocative tests, like Apley’s grind test and Apley’s distraction test, in conjunction with advanced imaging like MRI, can guide a physician to provide proper treatment. Treatment includes non-operative measures such as medication, i.e., NSAIDs, and physical therapy. Non-operative management is the first line of treatment for degenerative meniscal tears. Operative repair of a torn meniscus is indicated for peripheral tears because of rich blood supply. Surgical repair is better suited for vertical and longitudinal tears than for radial, horizontal, or degenerative tears. Definitive treatment of meniscal injury is beyond the scope of this article and is heavily dependent on the individual case characteristics.[1][3][5]

Enhancing Healthcare Team Outcomes

The Apley grind test to assess for meniscal injury can be performed by many healthcare professionals including the emergency department physician, sports physician, orthopedic nurse, phys-ical therapist, and the orthopedic surgeon. However, it is important to understand that the test is not 100% sensitive and an MRI should be done to confirm the diagnosis. Patients with meniscal injury should be referred to an orthopedic surgeon for definitive management.[1]


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Apley Grind Test - Questions

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A 75-year-old female presents to your office with left knee pain. She was standing on an airplane waiting to get off when she was accidentally pushed by the person next to her. This caused her to fall into the adjacent seat. Her left foot was planted on the floor at the time of the fall, and her knee sustained a twisting type injury. You perform a full examination of the knee and find it is swollen and tender along the joint line. The Apley grind test is used to assess which of the following?



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A 17-year-old football player presents to the emergency department with severe right knee pain. He was running with the ball and was tackled by two other players. One player was holding down his right leg keeping it planted on the ground while the other player came from the side and hit him directly on the right lateral knee. He has been unable to bear weight on the right knee and had to be carted off the field. On examination, he has a heart rate of 110 bpm, blood pressure 125/64 mmHg, respiratory rate of 16, temperature of 98.6F. He appears to be in moderate distress grasping his right knee. The right knee is significantly swollen with a large joint effusion and tender to palpation along the joint line and anterior tibia. The exam is limited secondary to pain, but there is increased laxity on anterior drawer, and severe pain and laxity with applying a valgus force. Apley compression test is positive for pain. Which of the following injuries is less likely to be seen in association with one another?



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An 87-year-old female presents with left knee pain. It started 2 weeks ago while she was getting up out of a chair. She says she just “twisted funny” as she was standing up. Since then, she has had pain, stiffness and feels like the knee is locking at times. She has no previous known injuries to the knee. You perform an exam, and it shows mild swelling and tenderness along the joint line. Apley grind test is positive while anterior drawer test is negative. You suspect a degenerative meniscus tear. Given this scenario, which should be your first line of therapy?



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A 35-year-old male presents with left knee pain. He is a seldom active and was in the batting cage 2 days ago hitting baseballs with his friends. He remembers taking a swing and felt a sudden pain in his left knee. Since then, he complains of pain, locking when going up stairs, and mild swelling. He denies any previous injuries to the knee. You perform an exam, and it shows mild swelling and tenderness along the joint line. Apley grind test is positive while anterior drawer test is negative. You order an MRI which shows a meniscus tear. You both decide together that surgery would be the best course of action. Which of the follow tears would be best managed by arthroscopic repair?



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A 17-year-old male presents to your office with 1 week of right knee pain. He was walking down a flight of stairs, slipped, and believes he twisted his knee but is unsure of the exact mechanism. On examination, his right knee has a joint effusion. He has moderate discomfort with varus force to the knee. Apley grind test is negative for discomfort, but Apley distraction test produces a large amount of pain. Anterior drawer test is negative. McMurray test is negative for pain and restriction. You obtain an x-ray of the knee in your office which is unremarkable. Which of the following is the more likely injured structure?



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Apley Grind Test - References

References

The predictive value of five clinical signs in the evaluation of meniscal pathology., Fowler PJ,Lubliner JA,, Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 1989     [PubMed]
Mordecai SC,Al-Hadithy N,Ware HE,Gupte CM, Treatment of meniscal tears: An evidence based approach. World journal of orthopedics. 2014 Jul 18;     [PubMed]
Shiraev T,Anderson SE,Hope N, Meniscal tear - presentation, diagnosis and management. Australian family physician. 2012 Apr;     [PubMed]
Doral MN,Bilge O,Huri G,Turhan E,Verdonk R, Modern treatment of meniscal tears. EFORT open reviews. 2018 May;     [PubMed]
Frizziero A,Ferrari R,Giannotti E,Ferroni C,Poli P,Masiero S, The meniscus tear. State of the art of rehabilitation protocols related to surgical procedures. Muscles, ligaments and tendons journal. 2012 Oct;     [PubMed]

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