Continuing Education Activity
The Apley grind test, also known as the Apley compression test or the Apley test, is a maneuver performed to evaluate for meniscus injury. Clinicians usually perform it in conjunction with the Apley distraction test, which assesses for ligamentous injury. Meniscal injuries are very common and are associated with significant pain and morbidity. This activity describes the Apley grind test and its indications and contraindications and highlights the role of the interprofessional team in the management of patients with meniscus injuries.
- Describe how the Apley grind test is performed.
- Review the implications of pain with compression during the Apley grind test.
- Summarize the contraindications to the Apley grind test.
- Explain strategies to optimize care coordination among interprofessional team members to improve outcomes for patients affected by meniscus injuries.
Apley grind test (Apley compression test) is a maneuver performed to evaluate for meniscus injury. This test derives its name from the British orthopedic surgeon, Dr. Alan Graham Apley. Usually, clinicians conduct it in conjunction with the Apley distraction test. Meniscal injuries are very common and correlate 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 the assumption is that this relates to males engaging in more activities involving 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 provide appropriate treatment and a positive outcome for patients.
Anatomy and Physiology
The meniscus is a C-shaped cartilage that serves as a cushion between the proximal tibia and the distal femur, comprising 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, glycoproteins, proteoglycan, and cellular elements, and is about 70% water. Three ligaments attach to the meniscus. The coronary ligaments connect the meniscus peripherally. The transverse (inter-meniscal) ligament is anterior and serves as a connection between the medial and lateral meniscus. The meniscofemoral ligament joins 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 via diffusion. The cartilage structure of the meniscus serves as a shock absorber and cushion or for the knee joint. There are several types of possible tears of the meniscus. These include flap tear, radial tear, horizontal cleavage, bucket handle tear, longitudinal tear, and degenerative tear.
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 presents along the knee joint line. Common patient complaints include pain and mechanical complaints such as locking, clicking, catching, locking, or inability to extend the knee fully. Commonly, these injuries occur with accompanying ligamentous injuries. When a force is applied to the lateral knee, it can result in an injury complex the "unhappy triad." This group of injuries includes damage to the medial meniscus or lateral meniscus with concomitant injury to the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL). During an orthopedic and physical examination, joint line tenderness, joint effusion, and impaired range of motion are common findings.
Apley's grind test should not be performed on patients with gross deformities of the knee. In the setting of significant trauma with knee deformation with obvious fracture or dislocation, Apley's grind and distraction tests, as well as other provocative tests, should be deferred until there are results from reimaging techniques. Special consideration and technique adjustments should take place for patients with previous amputations.
There is no special equipment required to perform this test. Only a standard exam table is needed.
No extra personnel is necessary to perform this test. Only the provider and the patient are required.
Apley's grind test is performed with the patient in a standard examination gown and laying in the prone position on the examination table.
With the patient in the prone position, the knee 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 occurs 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 along with compression. If there is pain or restriction with compression and internal or external rotation, this is a positive test. If the patient experiences pain over the medial aspect of the knee, this is indicative of a medial meniscus injury. Alternatively, if the patient experiences pain 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 force 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 significantly decreases the likelihood of meniscal pathology. By nature of the distraction force, the force applied to the meniscus becomes reduced considerably.
One complication of the Apley's grind test is local knee pain, but this is necessary to elicit, as that indicates a positive test. As stated in the contraindications section, the examiner should not perform this test 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.
Diagnosis of a meniscal injury is by physical/orthopedic examination and provocative tests, like Apley’s grind test and Apley’s distraction test, in tandem 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 and conservative 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. The definitive treatment of meniscal injury is beyond the scope of this article and is heavily dependent on the individual case characteristics.
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, physical therapist, and the orthopedic surgeon. However, it is crucial to understand that the test is not 100% sensitive, and an MRI should confirm the diagnosis. Patients with meniscal injury should receive a referral to an orthopedic surgeon for definitive management.