Continuing Education Activity

The Apley grind test, also known as the Apley compression test or the Apley test, is a maneuver performed to evaluate 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.

Objectives:

• 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.

Introduction

The Apley grind or compression test is a physical examination maneuver first described by the British orthopedic surgeon Alan Graham Apley. It is commonly performed to evaluate potential meniscal injury of the knee, often in conjunction with the Apley distraction test.

Meniscal injuries are prevalent and correlate with significant pain, morbidity, and missed time from school, sports, and work. Meniscal injuries are very uncommon in patients 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, such as contact sports.

Prompt diagnosis of these injuries with the proper physical examination, provocative tests such as the Apley grind test and Apley distraction test, and advanced imaging such as magnetic resonance imaging (MRI) are essential to provide appropriate treatment and a positive outcome for patients.[1]

Anatomy and Physiology

The lateral and medial menisci are accessory structures of the knee joint. A meniscus is a C-shaped cartilaginous pad between the opposing articular surfaces of the proximal tibia and the distal femur. The average width of the meniscus is 10 mm to 12 mm, and the average thickness is 4 mm to 5 mm. The meniscus is made of fibroelastic cartilage and serves as a cushion and shock absorber within the joint. 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 or inter-meniscal ligament is located anteriorly and connects 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 blood supply to the meniscus is derived from the medial inferior genicular artery and the lateral inferior genicular artery. Meniscal blood supply is known to be very poor, especially in the central portion, which gets most of its nutrition via diffusion.

There are several types of meniscal tears. These include flap tears, radial tears, horizontal cleavage tears, bucket handle tears, longitudinal tears, and degenerative tears.[1]

Indications

A meniscal injury 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, or inability to extend the knee fully.

Ligamentous injuries commonly accompany meniscal injuries. An external force applied to the lateral knee can result in an injury complex known as the "unhappy triad." This group of injuries includes damage to the medial 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.[2]

Contraindications

The Apley grind test should not be performed on patients with gross knee deformities. In significant trauma with knee deformation and obvious fracture or dislocation, all provocative tests, including the Apley grind and distraction tests, should be deferred until imaging results are available. Additionally, special consideration and technique adjustments should occur for patients with previous amputations.[3]

Equipment

There is no special equipment required to perform this test. Only a standard exam table is needed.[4]

Personnel

No extra personnel is necessary to perform this test. Therefore, only the provider and the patient are required.

Preparation

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

Technique or Treatment

With the patient in the prone position, the knee being tested is flexed to 90 degrees while the other leg is fully extended, resting on the exam table. The examiner should apply a downward axial loading force to compress the knee; this occurs by compressing down on the sole while using the other hand to stabilize the posterior thigh. Internal and external rotation should be applied along with compression.

The Apley compression test is considered positive if there is pain or restriction with compression and internal or external rotation. If the patient experiences pain over the medial aspect of the knee, this indicates a medial meniscus injury. Alternatively, if the patient experiences pain over the lateral aspect of the knee, this indicates a lateral meniscus injury.

The Apley compression test is commonly performed with the Apley distraction test, which tests for ligamentous injury rather than meniscal injury. To perform the distraction test with the patient in the same prone position, the examiner will pull up on the affected leg instead of providing a downward loading force. 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 the nature of the distraction force, the force applied to the meniscus becomes reduced considerably.[5][6]

Complications

There are no reported complications to the Apley compression test. While patients may experience localized knee pain, 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 existing fractures or potentially converting a closed fracture to an open fracture.

Clinical Significance

The diagnosis of a meniscal injury is made using physical examination and provocative tests, like the Apley compression and distraction tests, in tandem with advanced imaging like MRI.[4] Treatment of meniscal injuries includes non-operative measures such as medication and physical therapy; this conservative management is the first line of treatment for degenerative meniscal tears. Surgical repair of a torn meniscus may be indicated for peripheral tears because of the rich blood supply. Surgical repair is better suited for vertical and longitudinal tears than radial, horizontal, or degenerative ones. The definitive treatment of meniscal injury is beyond the scope of this article and is heavily dependent on individual case characteristics.[1][5][7]

Hashemi et al. compared the Apley compression test, McMurray test, and Thessaly test in 86 patients and then confirmed their findings through MRI knee and arthroscopy. The Thessaly test was superior to the other clinical tests (P < 0.001) when evaluating meniscal injuries. Thessaly test results were superior in terms of sensitivity (90.6%), specificity (90.7%), accuracy (90.69%), and positive and negative predictive values (85.3 and 94.2). In this study, the author compared the McMurray and Apley tests and found no statistically significant difference (P=0.267).[4] 

A prospective observational study was conducted on 106 patients by Shekarchi et al. Compared to MRI results, results of the McMurray test and findings of medial joint-line tenderness were far more specific than those of the Thessaly test (89.1% and 88.0%, respectively); the Thessaly test was more sensitive for medial meniscus tears (56.2%). Regarding lateral meniscus tears, the McMurray test was the most sensitive (56.2%), while all other tests were equally specific.[8] 

In a metanalysis, Meserve et al. demonstrated that the Apley compression test had higher specificity and lower sensitivity when compared to the McMurray test.[9] A systematic literature review has shown that despite poor intertester reliability and sensitivity, the McMurray test might be rather specific, particularly concerning the lateral meniscus.[10] 

A meta-analysis conducted by Hegedus showed that it is best to employ a variety of tests to diagnose a meniscal tear rather than relying just on one test. These clinical tests will be less helpful in identifying meniscal disease when anterior cruciate ligament pathology or chondromalacia is present.[1]

Enhancing Healthcare Team Outcomes

Many interprofessional healthcare team members can perform the Apley compression test to assess for meniscal injury, including emergency and sports medicine providers, orthopedic nurses and surgeons, chiropractors, and physical therapists. However, it is crucial to understand that the test is not 100% sensitive, and an MRI should be utilized to confirm the diagnosis.[4]

Patients with meniscal injuries should receive a referral to an orthopedic surgeon for definitive management.[1] Interprofessional activity coordination and open sharing of exam results and other case information will guide the management of knee injuries resulting in optimal outcomes.[Level 5]