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Al-Othman ET AL
A Simple Outpatient Test for proprioception in The Anterior Cruciate Ligament – Deficient Knee
Abdullah Al-Othman , FRCS, JMC(Ortho)*
Mohammed Moussa, MCh (Ortho),PhD*
Moammed Zakaria Eraky, MD*
Samir Al-Gazzar, MSc, PhD**
*College of Medicine & **College of Applied Medical Sciences
King Fahd Hospital of the University, King Faisal University, KSA.
Saudi Sports Medicine Journal, 2002
ABSTRACT
Proprioception was quantified in 32 patients who had an arthroscopically documented complete anterior cruciate ligament tear using a simple single-limb Standing test. An age-matched control group underwent identical testing. Control subjects demonstrated identical values between their two limbs with the mean variation being 4.8%. The test group, however, showed significantly higher mean values for the injured compared with the noninjured limb, the mean variation being 43.8%. Patients who have a complete tear of the anterior cruciate ligament may experience a decline in proprioceptive function of their knees. This can be tested clinically using a simple single-limb standing test in an outpatient setting.
The proprioceptive role of the anterior cruciate ligament (ACL) has been con- firmed by morphologic studies in humans,(1,2) and by neurophysiologic measurements.(3) While clinical evidence indicates that the ACL provides proprioceptive functions. joint position, movement senses. and postural control have been quantified in patients with and without a functioning ACL using complicated and experimental testing devices.(4,8) Proprioception also was tested using similar devices in ACL-reconstructed Knees (9,10) and after knee arthroplasty.(11)
This article describes a simple clinical test that objectively measures the
From the Departments oforthopedic Surgery
and Physiotherapy, King Fahd Hospital of the
University Al-Khobar, Saudi arabia.
Reprint requests: Abdullah Al-othman.
FRCS, JMC (Ortho), Dept of Orthopedic
Surgery. King Fahd Hospital of the University,
PO Box 2845, Al-Khobar, 31952, Saudi Arabia.
proprioceptive functions of the knee.
This test can be performed routinely in an outpatient setting.
MATERIALS AND METHODS
Thirty-two consecutive patients with chronic knee instability and a suspected tear of the ACL were examined for knee proprioception at King Fahd
University Hospital. Al Khobar. All of the patients were men with an average age of 28.3 years (range: 20 to 37Y).
Complete rupture of the ACL was confirmed athroscopically in all of the patients. All had at least a grade II Lachman test and a positive pivot-shift test. There were no other clinical signs of major ligamentous injury or severe meniscal lesions in the affected knees.
Al1 of the patients had a normal contralateral lower extremity.
Proprioception testing of the knees was done before arthroscopy for the study group using a simple single-limb standing test. This was to measure
changes in joint position, movement senses, and postural control. All external clues to limb position or motion were eliminated except those originating from the examined limb. Patients wore thick cotton socks and were instructed to keep both limbs adequately separated to neutralize cutaneous sensations. Subjects also wore blind-folds to remove visual input.
The subjects were instructed to stand in a standardized position with the tips of the big toes of the both feet at a reference 0-line on a specially constructed wooden platform (Fig. 1). Next, the subject was instructed to stand while raising the tested limb (knee) to about 90 degrees of flexion at the knee and hip joints (Fig. 2) and then to return the foot back to the original position (tip of the big toe at 0-line). Any deviation from this line was measured in centimeters with forward deviation in positive and backward deviation in negative (Fig. 3).
Each subject was given two test runs
with open eyes to be familiar with the procedure. Six repetitions then were performed on each subject three on each limb in a random sequences. A mean value for the deviations from the reference 0-nline was recorded for each limb. Testing was done in a blind manner so that the examiner who did not know which limb (knee) had been injured. A control group of 30 sex- and age-matched healthy medical students also was tested, and both limbs were tested in all subjects.
Statistical analysis of the study and control data was performed using independent and paired t-tests. A level of P<.05 was chosen for statistical significance.
RESULTS
The control group demonstrated virtually identical mean values between their two limbs; the mean variation was 4,8%. The test group, however. showed a significantly higher mean value for the injured versus the normal (non-injured) limb (P=.009); the overall mean variation between the two limbs
was 43.8% (Table 1). Moreover, the average deviation of the injured limbs in the study group differed significantly from that of the right limbs in the control group (P<.05), and the mean variation was 40.9% (Table 2).
DISCUSSION
Proprioceptive dysfunction in ACL-deficient patients has been tested using complex experimental equipment in many recent studies. Joint movement and position senses were evaluated by Barrack et al,(4) Corrigan et al,(6) and barrett,(9) while postural control was measured by stabilometric tests in other studies.(7,8)
The clinical test described in this study depends on proper appreciation of changes in joint position and movements, and adequate equilibrium of postural control during the procedure.
Other cutaneous and visual sensory input that might affect these proprieceptive functions were eliminated.
In the present study, significant impairment of proprioceptive functions was found when testing the injured limb compared with the non-injured limb as well as with the control group; the former was much more significant.
This is probably because in the study group, impaired afferent impulse are generated from the rising as well as the supporting limbs with reflex motor activity in both the ipsilateral and contrlateral limb.(7) These results are in accordance with those of Barrack et al (4) and Beard et al.(5)
The described test is a simple Clinical evaluation that objectively measures
the proprioceptive functions of the injured limb with the ACL-deficient knee. It does not need special equipment or instruments except for a measuring tape. The wooden platform used in this study can be omitted for any smooth reference line on the floor as the 0-line. So the test can be done on a routine basis in a regular outpatient setting.
Further studies are being conducted to assess the value of the test in patient selection for surgery, correlation with the severity of knee instability, and the effect of rehabilitation programs.
REFERENCES
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Simple Test for ACL
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