After I tore my anterior cruciate ligament, I fell on the ground and didn’t move for a few minutes. Eventually I walked off to the side of the field I was on, relaxed for maybe 30 minutes, then went to the bar with the guys I was playing flag football with. I didn’t feel great, but I had felt plenty worse.
The next day I couldn’t walk. I go to the ER and the physician tests my ACL, feels its solid, tells me to check in with an orthopedist in a few days if I’m still feeling symptoms. Great. ACL isn’t torn. This can’t be too bad.
The next day, two days after tearing the knee up, I work a 10 hour day. That’s ten hours of standing and walking. Again, didn’t feel great, but it was doable.
My symptoms are gone after a few days. After a week I’m back out on the field and my knee buckles on me. “Guess I’m not feeling as well as I thought.” I take some more time to heal up.
Months later I’m still having trouble. I go to an orthopedist and in about five seconds I’m told my ACL is torn. What the hell?
I’ve had my ACL tested by three non-orthopedists. One ER physician, one physical therapist, and one primary care physician. I eventually learned all three did the test wrong. Here is why you should never bother with the opinion of a non-ortho for this type of stuff.
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They don’t have the sensory skills
Never mind doing the test properly, non-orthopedists don’t do these tests everyday. With the ACL, we’re talking about the anterior drawer and Lachman test.
A Lachman is a slightly modified anterior drawer test. The gist of the tests are the same: You’re observing how much the tibia anteriorly translates. (White arrow above.) Like pulling a drawer forward. The anterior cruciate ligament, when intact, will prevent excessive anterior translation.
These tests are dealing with differences of millimeters, along with various perceptions, such as a “clunk” from the ACL engaging. It takes time to get this sense of feel down. Time and practice. Regular practice. Most orthopedists do this regularly. Most non-orthos do not.
Another thing to look out for is the hamstrings engaging. The anterior cruciate ligament helps prevent anterior translation of the tibia.
Original image from: http://www.orthopaedicsone.com/download/attachments/4554895/lachman+7.JPG
When the tibia is pulled into anterior translation, the ACL should engage and help pull the tibia back.
So do the hamstrings.
Notice the similarities between the hamstrings and ACL. Similar line of pull, both have proximal tibial attachments, etc.
If the hamstrings fire during these tests they can give a false negative -your ACL is fine- even though the ACL isn’t there. (If you’re wondering if this is one way people can get by with no ACL, yes.) Especially if you’re just after the injury where likely everything is tense. Again, you need a good sense of feel for this. Feeling the hamstrings contract is much easier than dealing with the millimeters of the tibial translation, however,
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You have to actually touch the hamstrings in order to know if they’re contracting
First way I’ve seen three people do this test wrong: They didn’t have one hand on my hamstrings while the other was pulling on the tibia.
This is good:
One hand on femur, so it can touch the hamstrings; other hand on tibia, so it can be pulled anteriorly.
This is not:
With both hands on the tibia (last image above), you can’t feel if the hamstrings contract. Some will place the hands high enough on the tibia that they can feel the hamstrings somewhat, but it’s not the same as one hand under the hamstrings and one under the tibia.
Not to mention when I see people do this like the above -butt on foot, both hands on tibia- I see people yank the fuck out of the knee. If a ligament is gone, there is no need to pull for dear life. All that does is make the hamstrings more likely to contract, and potentially piss off the patient’s knee. A good orthopedist will find out your ACL is torn with you barely realizing they did anything.
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Body positioning influences hamstring tone
The next way I’ve seen two physicians screw this up is they didn’t have me completely on my back. Think about laying flat on the floor. As you lean up more and more, you get more and more of a stretch in the back of your legs. This is how many people stretch their legs. The hamstrings get pulled on more and more. (If you want a detailed look at hamstring anatomy and this, see here.)
As this person goes from completely on their back, to more and more upright, to more and more leaned over, the hamstrings get pulled more and more:
The more upright someone is, the more likely the hamstrings are already engaged. A person really needs to be fully supine to help relax the hamstrings. One surgeon I talked to said the person must be supine. Note this is to help relax the hamstrings. It’s not a guarantee. They still need to be touched.
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Primary care physicians don’t know what they’re doing with this stuff. The physical therapists are a little better, but not much. My experience, ONLY orthopedists, and probably really only the sports oriented ones, know ACLs like you need to know them. This goes for the clinical exam, as well as assessing imaging. (Rehab is different.) I also had a radiologist tell me my ACL was fine. When I asked three orthopedists about that same MRI? All knew it was torn in seconds.
(If you have an insurance plan dictating you go to something like primary care first, that’s fine. But insist on seeing an orthopedist.)
To some degree, the others aren’t trained in this, so it’s understandable. To another degree, don’t do a damn test if you’re not doing it properly, or don’t do it often. Or, if you’re going to do it, you stipulate LOUDLY and repeatedly, “I don’t do this test regularly, so I suggest you still go to an orthopedist. I don’t have the feel they have.” Which is what I do whenever I test someone’s legs, which is practically never, because I already know I’m guessing. And I don’t want a client who has a lot of trust in me to think, “Eh, he seems to know what he’s doing. He’s probably right, nothing is torn. I won’t bother with an orthopedist.”
Otherwise you end up sending people off running with no ACL, as if they have one, like was done to me.
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tomslittlebrain
April 12, 2015
I’ve notice you make a lot of sweeping statements on this blog. If only I could be bothered to figure out how to stop receiving emails from this site.
The problem with the anterior draw and lachmans test are their poor specificity and sensitivity… They work better in a sub acute setting – the reason you got a negative test was most likely due to the acute stage of the injury and the inflammation surrounding the joint making it nigh on impossible to get a ‘reliable’ measuring.
Also, a complete ACL tear is pretty obvious on palpation and assessment, and subjectively to the patient as you usually get MCL and medial Meniscus trauma at the same time. yours was probably minor – owing to the fact that you could get up and walk and play again not many weeks later; true ACL tears are nasty.
Also over here in the UK orthopaedic surgeons are not working privately (AKA more ops = more money) but work for the NHS so they are not as happy to operate on anything and everything they see, mainly be cause they know it’s isn’t always appropriate.
Maybe do a little research before you spout shit from now on.
Some basic searches on Medline, science direct and some textbooks Etc will serve you well.
Thanks,
A UK physio.
reddyb
April 14, 2015
Edit: Added a closing comment.
Hey Tom,
And here I was thinking we were friends! https://breddydotorg.files.wordpress.com/2015/04/tom-sweetser-complimentary1.png
Anyways, it looks like you subscribed to my site three years ago: https://breddydotorg.files.wordpress.com/2015/04/tom-sweetser-email-follower.png
While I once got in a roller coaster of a relationship, and can understand the thrill, breaking up with me isn’t too bothersome. Each time you receive an email from me, there is an unsubscribe button. It’s right below the comment button: https://breddydotorg.files.wordpress.com/2015/04/unsubscribe-button-for-tom-sweetser.png
I’d unsubscribe you myself to help out, but I don’t believe I can do that. I can’t add or delete people from my email list. That’s all on the user.
First, your comment made me rethink the title of this post. I think it could be a little less hyperbolic sounding, so I changed it. Thank you for that.
Regarding my personal ACL timeline:
-It was roughly May 15th 2011 I tore my ACL.
-~May 16th an ER physician tests my ACL, says it’s fine. (To your point, if testing the knee with all that swelling can throw off the results, shouldn’t this be mentioned to the patient? I think you’re helping my argument here.)
-Mid-August of that year my leg gives out while attempting to run. Knee swells up again.
-Few days later an orthopedist tests my ACL; says it’s torn. Tells me to not even bother with a MRI, it’s that obvious. “Save your money.” That I originally sprained the LCL, and probably tore the medial meniscus too.
-Next day, I decide to get a MRI anyways. I didn’t like how confident he was and how quickly he was about to send me to surgery.
-Few days later, radiologist sends my report over. Tell me the ACL is normal and intact. Medial meniscus is torn though.
-I call the orthopedist, he tells me no, ACL is definitely torn. He just double checked the MRI. And had his colleague confirm.
-As I’m thoroughly confused and don’t know who to trust, I grab a physical therapist I personally know. One who experienced their own ACL tear. They test my ACL; say it seems fine to them.
-October I go to an orthopedist I grew up seeing (out of state, to get an opinion I trust). Does a Lachman test. Tells me “Your ACL is torn.” He looks at the MRI. “Here is the tear.” (And the meniscus too.)
-November I go to a third orthopedist. (Attempting to find a local one for surgery.) A resident comes in instead of the doctor. (I didn’t know this was going to happen.) Does a Lachman test. “Your ACL is torn.”
-The attending orthopedist (number four) comes in. Does a Lachman test. “Your ACL is torn.” (Discusses the medial meniscus on the MRI too.)
-December 23rd, 2011, I have surgery. Medial meniscal repair; partial lateral menisectomy; ACL reconstruction using hamstring autograft.
-April 2015, I see a new primary care doctor. They do the anterior drawer test after learning my ACL history. They perform the test as I outlined in this post -without me laying fully supine.
You stated the reason for my negative test was “most likely due to the acute stage of the injury.” My ACL was only tested once in the acute stages of the injury. Later on, a positive test was found immediately after a flare up. A negative test was found a few days later after this positive test. (Meaning the acute stage can’t explain this.) And then more positive tests were found after this negative test. (Don’t forget the radiologist’s opinion in there too.)
And none of this addresses the fact the test was done wrong in all circumstances where a negative test was found.
You say my injury was probably minor. If you don’t agree that a medial mensical tear, a lateral meniscal tear, an ACL rupture, and a LCL sprain qualify as more than minor, then we’ll have to disagree.
Much more has to do with why I, and many others, got by with no ACL, and a beat up meniscus, so well. I discuss some of this in the following post: http://b-reddy.org/2011/11/29/reconstructive-acl-surgery-is-it-beneficial/
That post was published I believe before you subscribed, but I listed many references in it. Hopefully this eases your thoughts about me “spouting shit” without references to literature:
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“Studies showing no difference in arthritis. Remember there are no randomized trials for this category:
Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes.
Prevalence of tibiofemoral osteoarthritis 15 years after nonoeprative treatment of anterior ligament injury: a prospective cohort study.
Studies showing reconstructed patients return have better rates of returning to the highest levels of activity:
Operative versus Non-Operative Treatment of Recent Injuries to the Ligaments of the Knee
Surgical or Non-Surgical Treatment of Acute Rupture of the Anterior Cruciate Ligament
Studies showing minimal if any differences in rates of return to activity:
Non-operative management of anterior cruciate ligament injuries in the general population (This is the best study done on more of your typical, non-extremely active, recreational athlete. There was basically 0 benefit found for these people having surgery. Including no difference in meniscal tears.)
Studies showing higher rates of meniscus tear in non-reconstructed patients:
Operative versus Non-Operative Treatment of Recent Injuries to the Ligaments of the Knee
Surgical or Non-Surgical Treatment of Acute Rupture of the Anterior Cruciate Ligament
A Randomized Trial of Treatment for Acute Anterior Cruciate Ligament Tears (The best study.)
Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes.”
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I also have many references listed in my recommended learning page. (http://b-reddy.org/what-i-read/) Along with in various posts. Along with textbook references For instance, here are the pubmed references listed on the recommended learning page:
Acetabular Labral Tears
Anterior Hip Joint Force Increases with Hip Extension, Decreased Gluteal Force, or Decreased Iliopsoas Force
Classification, Intervention, and Outcomes for a Person With Lumbar Rotation With Flexion
Clinical Examination Procedures to Determine the Effect of Axial Decompression on Low Back Pain Symptoms in People With Chronic Low Back Pain
Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement
Differences in Activity Limitation Between 2 Low Back Pain Subgroups Based on the Movement System Impairment Model
Differences in end-range lumbar flexion during slumped sitting and forward bending between low back pain subgroups and genders
Differences in lumbopelvic motion between people with and people without low back pain during two lower limb movement tests
Differences in symmetry of lumbar region passive tissue characteristics between people with and people without low back pain
Effect of Active Limb Movements on Symptoms in Patients with Low Back Pain
Effect of Hip Angle on Anterior Hip Joint Force during Gait
Effect of position and alteration in synergist muscle force contribution on hip forces when performing hip strengthening exercises
Further Examination of Modifying Patient-Preferred Movement and Alignment Strategies in Patients with Low Back Pain During Symptomatic Tests
Further examination of modifying patient-preferred movement and alignment strategies in patients with low back pain during symptomatic tests
Gender Differences in Modifying Lumbopelvic Motion during Hip Medial Rotation in People with Low Back Pain
Gender differences in pattern of hip and lumbopelvic rotation in people with low back pain
Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome
Hip Rotation Range of Motion in People With and Without Low Back Pain Who Participate in Rotation-Related Sports
It pays to have a spring in your step
Muscle Activation and Movement Patterns During Prone Hip Extension Exercise in Women
Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports
Reliability of Physical Examination Items Used for Classification of Patients With Low Back Pain
Diagnosis and Management of a Patient With Knee Pain Using the Movement System Impairment Classification System
Sex differences in lumbopelvic movement patterns during hip medial rotation in people with chronic low back pain
The effect of within-session instruction on lumbopelvic motion during a lower limb movement in people with and people without low back pain
The Relationship of Acetabular Dysplasia and Femoroacetabular Impingement to Hip Osteoarthritis: A Focused Review
Use of a Classification System to Guide Nonsurgical Management of a Patient With Chronic Low Back Pain
Use of a Movement System Impairment Diagnosis for Physical Therapy in the Management of a Patient With Shoulder Pain
Walking with Increased Ankle Pushoff Decreases Hip Muscle Moments
Regarding the Lachman and Anterior Drawer: My argument was not on how good these tests are. My argument was the test needs to be done properly. You can’t bother with worrying how good the test is before acknowledging if it’s not even done properly.
That said, google scholar tells me this is one of the most recent studies on “lachman sensitivity and specificity”:
“Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia”
Abstract
Purpose
The aims of this meta-analysis were to determine the sensitivity and specificity of the Lachman, pivot shift and anterior drawer test for acute complete ACL rupture in the office setting and under anaesthesia. It was hypothesized that the Lachman test is the most sensitive and the pivot shift test the most specific. Secondly, it was hypothesized that the sensitivity and specificity of all three exams increases when the examination is performed under anaesthesia.
Methods
An electronic database search was performed using MEDLINE and EMBASE. All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included.
Results
Twenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78. For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91. The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98.
Conclusion
In the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, completeACL rupture, while all three tests had comparable specificity. When the examination was performed under anaesthesia, the Lachman test still obtained the highest sensitivity, but the pivot shift test was the most specific.
Level of evidence
Meta-analysis of diagnostic test accuracy, Level II.
Link: http://link.springer.com/article/10.1007/s00167-012-2250-9
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Next,
“The Lachman test is the most sensitive and the pivot shift the most specific test for the diagnosis of ACL rupture.”
Objective
To asses the validity of three physical diagnostic tests for the demonstration of rupture of the anterior cruciate ligament (ACL): the anterior drawer test, the Lachman test, and the pivot shift test.
Design
Meta-analysis of diagnostic studies.
Data sources
From computerised searches of Medline (1966–2004) and Embase (1980–2004), publications were selected that were written in English, French, German, or Dutch and in which the value of at least one physical diagnostic test for rupture of the ACL was assessed in comparison with the findings from arthrotomy, arthroscopy, or MRI as the reference standard.
Study selection and assessment
Two investigators independently selected the publications, assessed the methodological quality, and extracted data using a standardised protocol.
Outcomes
Wherever appropriate and possible, an estimate was made of the (pooled) sensitivity, specificity, and positive and negative predictive value of each test with the aid of a meta-analysis.
Main results
There were 17 studies identified. None of these reported blinded assessment of test, and only 2 performed the gold standard in all included patients. Summary estimates of sensitivity and specificity were 62% (95% CI 42 to 78%) and 88% (95% CI 83 to 92%) for the anterior drawer test, 86% (95% CI 76 to 92%) and 91% (95% CI 79 to 96%) for the Lachman test, and 32% and 98% (95% CIs could not be calculated) for the pivot shift test, respectively.
Conclusions
Physical diagnostic tests may be useful in the diagnosis of ACL ruptures. The clinical relevance of the test results, however, depends largely on the prior probability of the presence of such a rupture and is therefore different for general practitioners and specialists.
Link: http://www.sciencedirect.com/science/article/pii/S0004951406700691
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Also,
“Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: A meta-analysis”
Objective This systematic review summarizes the evidence on the accuracy of tests for assessing ACL ruptures of the knee.
Search strategy A computerized search of MEDLINE (1966–2003) and EMBASE (1980–2003) with additional reference tracking.
Selectioncriteria Articlesincludedwerewrittenin English, French, German, or Dutch, and addressed the accuracy of at least 1 physical diagnostic
test for ACL rupture, using arthrotomy, arthroscopy, or magnetic resonance imaging as the gold standard.
Data collection and analysis Two reviewers independently selected studies, assessed the methodological quality, and abstracted data using a standardized protocol. We calculated sensitivity, specificity, and likelihood ratios for each test and summary estimates, when appropriate and possible.
Main results Seventeen studies met the inclusion criteria. None assessed the index test and reference test independently (with blinding), and all but 2 displayed verification bias. Study results were heterogeneous. The pivot shift test seems to have favorable positive predictive value, and the Lachman test has good negative predictive value. The anterior drawer test is of unproven value.
Conclusions Reliable data are rare regarding the accuracy of physical diagnostic tests for ACL ruptures, especially in a primary care setting. For the time being, history taking and physical examination, albeit of limited use, should be considered with individual patient demands to provide the basis for further evaluation.
I thought this was a good quote:
“…and because primary care physicians will be less experienced in performing these tests, the tests will presumably be less accurate in a primary care setting.”
Link: http://dspace.ubvu.vu.nl/bitstream/handle/1871/27428/263624.pdf?sequence=2
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I am aware the numbers jump around on these tests. But considering the hard time you’re giving me, it seems you should probably make the statement on the lachman and anterior drawer test numbers -that they’re “poor”- a little more nuanced.
Next, I’m confused by your defense of me getting a negative test, and saying the go to orthopedic tests are “poor,” yet then declaring a complete ACL tear is “pretty obvious on palpation and assessment.” Seems contradictory.
Finally, regarding me being able to walk around after the injury, something I did for seven months before having surgery. (I did everything activity wise except play sports.): People have walked around with far worse things happen to them. The pain science world delves into this well. Here are some pubmed references from them I include on my learning resources page:
Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice.
Disrupted working body schema of the trunk in people with back pain
The Effects of Graded Motor Imagery and Its Components on Chronic Pain -A Systematic Review and Meta-Analysis
Graded Motor Imagery For Pathologic Pain
Graded motor imagery is effective for CRPS -A Randomized Control Trial
Managing chronic nonspecific low back pain with a sensorimotor retraining approach: exploratory multiple-baseline study of 3 participants.
Mislocalization of sensory information in people with chronic lower back pain
Neglect-like tactile dysfunction in chronic back pain
Pain and motor control of the lumbopelvic region- effect and possible mechanisms
The Pain of Tendinopathy- Physiological or Pathophysiological?
A randomized-controlled trial using a book of metaphors to reconeptualize pain and decrease catastrophizing in people with chronic pain
Tactile acuity and lumbopelvic motor control in patients with back pain and healthy controls
Tactile acuity is disrupted in osteoarthritis but is unrelated to disruptions in motor imagery performance
Hope that adequately addresses your points. Best of luck with things and thanks for being a reader for so long, even if it wasn’t always enjoyable. Good luck with your new site as well.
JP Danna (@JPDanna)
April 23, 2015
Unfortunately I didn’t come visit when I was in O’side in March. This deserves a keg. Keep up the good work!
reddyb
April 23, 2015
Maybe next time!
Valerie
July 16, 2016
So true! The ER doc I went to sent me home telling me nothing was wrong since I could walk. Only found out I had a torn ACL a couple of months later when my knee gave out playing sports. After that I saw a specialist who told me after a quick exam that I should get a MRI for suspected ACL tear. And he was right! Tore my meniscus too.
reddyb
July 17, 2016
I’ve unfortunately heard too many of these stories! Best of luck with your injury.