SHORT COMMUNICATION

Learning of Musculoskeletal Ligament Stress Testing in aGross Anatomy Laboratory

David A. Krause,* James W. Youdas, John H. HollmanProgram in Physical Therapy, Mayo School of Health Sciences, College of Medicine, Mayo Clinic, Rochester,Minnesota

Human anatomy in physical therapy programs is a basic science course serving as a foun-dation for subsequent clinical courses. Integration of anatomy with a clinical emphasisthroughout a curriculum provides opportunities for reinforcement of previously learnedmaterial. Considering the human cadaver laboratory as a fixed cost to our program, wesought opportunities to add value to the resource via vertical integration into a clinicalskills course taught later in the curriculum. We designed an opportunity for second-yearphysical therapy students to revisit the human anatomy laboratory to study select clinicalmusculoskeletal tests and the associated anatomy in a clinically relevant context. Studentsperformed select orthopedic ligament test on human cadavers, then incised specific struc-tures and repeated the tests. Students were able to feel and visualize the function of perti-nent anatomy associated with the clinical tests. Ninety-five percent of respondentsreported that the ligament stress testing experience enhanced their understanding of or-thopedic clinical tests with 91% reporting an enhanced understanding of anatomy relatedto specific clinical tests. Likewise, the experience was perceived as enjoyable and valuablewith 86% of respondents reporting the experience as enjoyable and 100% respondingthe experience should continue as part of the curriculum. Anat Sci Educ 4: 357–361. © 2011

American Association of Anatomists.

Key words: clinical tests; gross anatomy; ligament; physical therapy; musculoskeletal

INTRODUCTION

Human anatomy in physical therapy programs, similar tomedical schools, is typically presented in a traditional formatthrough a combination of lecture and human cadaver dissec-tion (Mattingly and Barnes, 1994; Drake et al., 2009). It is abasic science course typically occurring early in the curricu-lum serving as a foundation for subsequent clinical courses(Mattingly and Barnes, 1994). Because of reasons such ascosts associated with a human cadaver laboratory, timedemands to complete dissections, as well as advances in tech-

nology, alternate delivery methods have been advocated(Plack, 2000).

Integration of anatomy across a curriculum with an em-

phasis on clinically oriented teaching is advocated (Drake,1999; Holla et al., 2009). Integration throughout a curricu-

lum provides opportunities for reinforcement of previously

learned material. Clinical application allows students toappreciate the relevance of anatomy to practice. Both integra-

tion and clinical application facilitate transformation of

knowledge from a basic to a deeper understanding of anat-

omy for use in future clinical decision making. Although inte-

gration is advocated, a recent survey of 130 allopathic and

25 osteopathic medical schools in the United States revealed

most anatomy courses (71%) are stand alone courses and not

part of an integrated curriculum (Drake et al., 2009).Considering the human cadaver laboratory experience as a

fixed cost to our program, we sought opportunities to addvalue to the resource, rather than replace with another for-mat. In the doctor of physical therapy (DPT) program at theCollege of Medicine, Mayo Clinic, human anatomy is pre-sented in the fall semester of year one (six credit hours). Con-currently, second-year DPT students learn clinical musculo-skeletal evaluation skills in a course titled Management of

*Correspondence to: Dr. David A. Krause, Program in PhysicalTherapy, 1102 Siebens Building, Mayo Clinic, 200 First St SW,Rochester, MN 55905, USA. E-mail: krause.david@mayo.edu

Received 23 May 2011; Revised 27 June 2011; Accepted 28 June2011.

Published online 27 July 2011 in Wiley Online Library(wileyonlinelibrary.com). DOI 10.1002/ase.248

© 2011 American Association of Anatomists

Anatomical Sciences Education NOVEMBER/DECEMBER 2011 Anat Sci Educ 4:357–361 (2011)

Musculoskeletal Conditions I (MSK I—four credit hours).With first-year DPT students completing dissections near theend of the fall semester, we designed an opportunity for sec-ond-year students to revisit the human anatomy laboratory tostudy select clinical musculoskeletal tests presented in MSK Iand the associated anatomy in a clinically relevant context.The purpose of this report is to describe our experience witha clinically based learning experience in a human anatomylaboratory and present learner impressions of the experience.This project was deemed exempt by the IRB of Mayo Clinic(45 CFR 46.101, item 1).

METHODS

Twenty-six second-year DPT students participated in thelearning experience. Three faculty members were available toassist with dissections and answer questions. The learning ex-perience occurred during a 2.5-hour session in a human anat-omy laboratory setting. Student to cadaver ratio was 2:1. Theprimary activity of the session was performing specific clinicalligamentous stress tests, identifying and sectioning specificcapsular and ligmentous tissue, and then repeating the spe-cific clinical tests (Figs. 1 and 2). Students also reviewed re-

gional anatomy associated with the specific tests. The follow-ing describes a tissue sectioning sequence at the knee as anexample. Prior to incising ligamentous structures about theknee, a series of select tests was performed. Tests, asdescribed in Magee’s Orthopedic Physical Assessment text-book (Magee, 2008), performed included varus and valgusstress tests at 08 and 308 of knee flexion, anterior and poste-rior drawer tests, and a Lachman’s test. The medial collateralligament was subsequently incised, and all tests wererepeated. Students observed marked medial laxity with a val-gus producing stress test at 308 of knee flexion. Next, the an-terior cruciate ligament was cut, and the knee tests wereagain performed. Obvious laxity occurred with valgus stresstests at both 08 and 308 of knee flexion and also with the an-terior drawer and Lachman’s tests. Staging the cutting of liga-ments clearly demonstrated the role of the medial collateralligament as a primary restraint to valgus force and the ante-rior cruciate as a primary restraint to anterior translation ofthe tibia on the femur and a secondary stabilizer of the kneeto valgus force with the knee in extension.

Prior to the anatomy laboratory experience, studentsreceived a handout describing specific clinical tests to be per-formed, anatomic structures to be identified and subsequentlyincised, and the associated regional anatomy. All clinical testshad been previously presented and practiced in a clinicalskills laboratory. An outline of the specific tests performedand the structures sectioned is presented in Table 1.

At the conclusion of the experience, a seven-item surveyusing a five-point Likert scale and a three-item questionnairewere provided to student participants to gather impressionsof the laboratory experience. The three open-ended questionssought to discover what the students liked and disliked aboutthe experience and gather suggestions for improvement. Com-pletion of the survey and questionnaire was optional and allresponses remained anonymous.

RESULTS

Twenty-two of 26 students (85%) participating in the experi-ence returned the survey and questionnaire for analysis.Results of the survey are presented in Table 2. Ninety-fivepercent (n 5 21) of respondents reported that the ligamentstress testing experience enhanced their understanding of or-thopedic clinical tests and measures with 91% (n 5 20)reporting an enhanced understanding of anatomy related tospecific clinical tests. Likewise, the experience was perceivedas enjoyable and valuable with 86% (n 5 19) of respondentsreporting the experience as enjoyable and 100% (n 5 22)responding the experience should continue as part of the cur-riculum. Ninety-five percent (n 5 21) disagreed or stronglydisagreed that the experience did not enhance their interest inanatomy. Only 73% (n 5 16) reported that the experienceimproved their confidence in interpreting clinical results.

DISCUSSION

The primary goals of this unique experience were to (1)enhance the understanding of clinical tests and concepts pre-sented in MSK I and (2) provide an opportunity to revisitand review gross anatomy in a human anatomy laboratory. Asecondary goal was to maximize the educational ‘‘value’’ ofthe human anatomy investment.

Table 1.

List of Musculoskeletal Tests Performed and Ligaments Incised

Joint Tests performeda Ligamentsincised

Shoulder Crank

Relocation

Anterior drawer

Posterior drawerPush/pull

Sulcus

Feagan

AC distraction

Anterior

glenohumeral

Superior

glenohumeralConoid

Trapezoid

Acromioclavicular

Elbow Varus/valgus stress Ulnar collateral

Hand/Thumb

Varus/valgus stress:

MCP, PIP, DIP joints

Collateral

Ulnar collateral

Knee Varus/valgus stress

Anterior drawer

Posterior drawer

Lachman’sDial test

Lateral glide of patella

Tibial collateral

Fibular collateral

Anterior cruciate

Posterior cruciateMedial

patellofemoral

Ankle Anterior drawer

Talar tiltExternal rotation

Anterior talofibular

CalcaneofibularAnterior

talofibular

Posterior

talofibularInterosseous

aAll tests performed are based on Magee (2008); AC, acromiocla-vicular; MCP, metacarpophalangeal; PIP, proximal interphalan-geal; DIP, distal interphalangeal.

358 Krause et al.

On the basis of the students’ feedback, we were successfulin designing a positive experience to enhance learning.Although we did not objectively measure with an examina-tion, 95% (n 5 21) responded their understanding of clinicaltests was enhanced and 91% (n 5 20) reported enhancedlearning of the associated anatomy. The response of our stu-dents is similar to previous reports of positive student percep-tions in gross anatomy and the value of the cadaver experi-ence to professional medical development (Pearse and Park-ing, 2000; McKenzie and Gutierrez, 2007; Dusseau et al.,2008; Johnston and McAllister, 2008; Wilson et al., 2009;Bockers et al., 2010). Wilson et al. (2009) designed a clinicalexperience in which five invasive procedures were performed.Second-year medical students were organized into either agroup that practiced the five procedures on cadavers or agroup that participated in a traditional review laboratory.They found the anatomy review combined with procedureexercises superior to a traditional anatomy review enhancingboth anatomy and clinical knowledge on post-test scores.They speculated that the difference between the two groupswas in part due to the level of engagement associated withlearning the clinical procedures. Similarly, Dusseau et al.(2008) developed an anatomy correlations course, which waspresented concurrently with gross anatomy. The objectivewas to enhance the understanding of physical examinationtechniques. They found introducing clinical examination skillsconcurrently with Gross Anatomy resulted in improved anat-omy scores.

Oblinger and Oblinger (2005) discussed the classification ofindividuals according to birth year. Generation group namesinclude Baby Boomers, Generation X, and Generation Y. Gen-

eration Y, also called ‘‘Millennials’’ or the ‘‘Net Generation,’’are those individuals born around the mid 1970’s to the early2000’s. Students in our cohort fit into this grouping. Specificlearning characteristics identified with these individuals includea preference for experiential and engaging learning, and interac-tivity and collaboration (Skiba and Barton, 2006). Faculty arechallenged to design learning experiences considering thesereported preferences. Although the format of the experiencemay appeal to multiple generational groups, we believe the for-mat of our anatomy laboratory experience was well alignedwith learning preferences associated with the Net Generation.

Student’s anatomy education goes through a process of ini-tial exposure serving as a building block of knowledge, forget-ting of knowledge following the initial exposure, and later rein-forcement or retrieval of knowledge through restructuring andapplication (Smith and Mathias, 2011). Performing clinical testsin the laboratory setting challenged students to recall and relatepreviously learned material to relevant clinical application. Sur-veys of medical students reveal a desire for ‘‘vertical’’ integra-tion of anatomy with exposure throughout a curriculum (Fitz-gerald et al., 2008; Smith and Mathias, 2011). This desire forintegration and reinforcement is reflected in the comment by aparticipant who stated, ‘‘it was helpful to be able to see whatligaments we are testing with the special tests. I didn’t feel likeI learned the ligaments very well in anatomy so it was nice tobe able to go back and study them.’’

An additional purpose of the laboratory session was toallow students the opportunity to experience ‘‘positive’’ tests. Inthe MSK I course, musculoskeletal clinical tests were demon-strated, and students practiced the tests on classmates in a clini-cal skills laboratory. While the opportunity to experience

Table 2.

Results of the Seven Item Survey of Anatomy Laboratory Experience for Ligament Testing during the Management of theMusculoskeletal Conditions I (MSK I) course

Question Response (percentage) N Mean SD

1 2 3 4 5

1 The MSK I anatomy ligament stress testing experience enhanced

my understanding of the association of anatomy to clinicalmusculoskeletal conditions

0 0 9 55 36 22 4.3 0.6

2 The MSK I anatomy ligament stress testing experience enhanced

my understanding of orthopedic clinical tests and measures

0 0 5 59 36 22 4.3 0.6

3 The MSK I anatomy ligament stress testing experience should be

part of the curriculum / MSK I.

0 0 0 45 55 22 4.6 0.5

4 Performing selective sectioning of ligament and capsular

structures and then performing clinical ligament tests enhancedmy motivation to learn

0 5 23 45 27 22 4.0 0.8

5 Performing selective sectioning of ligament and capsular

structures and then performing clinical ligament tests did notenhance my interest in anatomy

50 45 0 5 0 22 1.6 0.7

6 Performing selective sectioning of ligament and capsular

structures and then performing clinical ligament tests enhanced

my enjoyment in the anatomy laboratory.

0 5 9 36 50 22 4.3 0.8

7 Performing selective sectioning of ligament and capsular

structures and then performing clinical ligament tests enhanced

my confidence in interpreting results of clinical tests

0 5 22 32 41 22 4.0 0.8

Likert scale: 1 5 strongly disagree; 2 5 disagree; 3 5 unsure; 4 5 agree; 5 5 strongly agree.

Anatomical Sciences Education NOVEMBER/DECEMBER 2011 359

‘‘normal’’ tests was afforded in this setting, the ability to experi-ence ‘‘positive’’ or ‘‘abnormal’’ finding was limited as studentsin general do not have pre-existing pathology. As indicated bystudent responses, while students acknowledged cadavers didnot necessarily replicate exactly how a ‘‘real’’ patient wouldfeel, they were able to feel and appreciate differences beforeand after compromising supporting ligament structures. Asstated by one student, ‘‘I really liked learning the special testsand practicing them on our normal colleagues and then section-ing the cadavers to feel the difference.’’

Additionally, students could directly palpate landmarks andvisualize the function of supporting ligaments. As stated, ‘‘itwas nice to see the anatomy we would be putting our hands onwith patients.’’ Given the focus of the experience was under-standing the function of supporting structures associated withclinical tests and not interpretation of findings, it was not unex-pected that only 73% (n 5 16) reported the experienceimproved their confidence in interpreting clinical results.

Some authors advocate alternative methods such as com-puter-based instruction to deliver anatomy with many reportingno difference in learner outcomes between traditional anatomylaboratory-based instruction and the alternate methods (Plack,2000; Bukowski, 2002; McNulty et al., 2009). Outcome meas-ures are typically performance on an examination, which is pri-marily in the domain of recall knowledge or memorization.Pandey and Zimitat (2007) reported that successful studentsuse both surface and deep learning strategies with deep learninginvolving visualization and understanding in addition to memo-rization. The process of evaluating the contribution of specificligament and capsular structures to joint stability was intendedas a means to provide students an opportunity to engage deeplearning processes of investigating and visualizing and visualiz-ing functional anatomic relationships. This was reflected by onestudent’s response, which stated ‘‘the learning experienceallowed me to get both a hands-on and in-depth visual experi-ence.’’ While simple recall and identification of anatomic struc-tures was necessary, the performance of the clinical testsencouraged an understanding through application and visualiza-tion of supporting structures.

Costs associated with a human anatomy laboratory to aphysical therapy program can be significant (Plack, 2000).These costs provide incentive to explore alternate deliverymethods. Rather than decrease expense, we sought to explorestrategies to maximize the value of our current cadaverresource. While additional opportunities were available in theanatomy laboratory for second-year DPT students, we believethe clinical ligament stress testing presented is a specificexample of a learning experience that can add value to ahuman anatomy laboratory. Specifically, considering thecadaver and anatomy laboratory expense associated with thefirst-year DPT student anatomy course as a fixed cost, addi-tional use of the resource by second-year DPT students didnot increase costs to our program.

SUMMARY

We have described a learning session in a physical therapy pro-gram. While only a single session, this serves as a pilot projectto support exploring additional educational opportunities inthe human anatomy laboratory throughout a physical therapycurriculum. Based on the positive feedback from students,experiences such as this are valuable in reinforcing clinicallyrelated anatomy. We believe this presents a challenge to facultyto consider and design learning experiences to add to the edu-cational value of a human anatomy laboratory.

NOTES ON CONTRIBUTORS

DAVID A. KRAUSE, P.T., D.Sc., M.B.A, O.C.S., is an assist-ant professor in the Program in Physical Therapy at the Col-lege of Medicine, Mayo Clinic, Rochester, Minnesota. He isan instructor in the Anatomy for Physical Therapists Coursefor the first-year Doctor of Physical Therapy students and co-ordinator of Management of Musculoskeletal Conditions Ifor second-year students.

JAMES W. YOUDAS, P.T., M.S., is an associate professor inthe Program in Physical Therapy at the College of Medicine,

Figure 2.

Posterior drawer test at the knee.

Figure 1.

Valgus stress test at the elbow.

360 Krause et al.

Mayo Clinic, Mayo Clinic, Rochester, Minnesota. He is the co-ordinator and instructor in the Anatomy for Physical TherapistsCourse for the first-year Doctor of Physical Therapy students.

JOHN H. HOLLMAN, P.T., Ph.D., is an associate profes-sor in the Program in Physical Therapy at the College ofMedicine, Mayo Clinic, Mayo Clinic, Rochester, Minnesota.He is the director of the Mayo Program in Physical Therapy.

LITERATURE CITEDBockers A, Jerg-Bretzke L, Lamp C, Brinkmann A, Traue HC, Bockers TM.2010. The gross anatomy course: An analysis of its importance. Anat Sci Educ3:3–11.

Bukowski EL. 2002. Assessment outcomes: Computerized instruction in ahuman gross anatomy course. J Allied Health 31:153–158.

Drake RL. 1999. Anatomy education in a changing medical curriculum. Kaibo-gaku Zasshi 74:487–490.

Drake RL, McBride JM, Lachman N, Pawlina W. 2009. Medical education inthe anatomical sciences: The winds of change continue to blow. Anat Sci Educ2:253–259.

Dusseau J, Knutson D, Way D. 2008. Anatomy correlations: Introducing clini-cal skills to improve performance in anatomy. Fam Med 40:633–637.

Fitzgerald JE, White MJ, Tang SW, Maxwell-Armstrong CA, James DK. 2008.Are we teaching sufficient anatomy at medical school? The opinions of newlyqualified doctors. Clin Anat 21:718–724.

Holla SJ, Ramachandran K, Isaac B, Koshy S. 2009. Anatomy education in achanging medical curriculum in India: Medical student feedback on durationand emphasis of gross anatomy teaching. Anat Sci Educ 2:179–183.

Johnston AN, McAllister M. 2008. Back to the future with hands-on science:Students’ perceptions of learning anatomy and physiology. J Nurs Educ47:417–421.

Magee DJ. 2008. Orthopedic Physical Assessment. 5th Ed. St. Louis, MO:Saunders. 1152 p.

Mattingly GE, Barnes CE. 1994. Teaching human anatomy in physical therapyeducation in the United States: A survey. Phys Ther 74:720–727.

McKenzie AL, Gutierrez B. 2007. The Varied-Integrative-Progressive (VIP)model for anatomy instruction in physical therapist education. J Phys TherEduc 21:17–29.

McNulty JA, Sonntag B, Sinacore JM. 2009. Evaluation of computer-aidedinstruction in a gross anatomy course: A six-year study. Anat Sci Educ 2:2–8.

Oblinger DG, Oblinger JL (Editors). 2005. Educating the Net Generation. 1stEd. Boulder, CO: EDUCAUSE. 264 p. URL: http://www.educause.edu/educa-tingthenetgen [accessed 27 April 2011].

Pandey P, Zimitat C. 2007. Medical students’ learning of anatomy: Memorisa-tion, understanding and visualisation. Med Educ 41:7–14.

Pearse E, Parkin I. 2000. Undergraduate medical students’ views on the valueof dissecting. Med Educ 34:493.

Plack MM. 2000. Computer-assisted instruction versus traditional instructionin teaching human gross anatomy. J Phys Ther Educ 14:38–43.

Skiba DJ, Barton AJ. 2006. Adapting your teaching to accommodate the netgeneration of learners. Online J Issues Nurs 11:5.

Smith CF, Mathias HS. 2011. What impact does anatomy education have onclinical practice? Clin Anat 24:113–119.

Wilson AB, Ross C, Petty M, Williams JM, Thorp LE. 2009. Bridging thetransfer gap: Laboratory exercise combines clinical exposure and anatomyreview. Med Educ 43:790–798.

Anatomical Sciences Education NOVEMBER/DECEMBER 2011 361