KIN 191AAdvanced Assessment of Lower Extremity Injuries

KNEE/PATELLOFEMORALARTICULATION

EVALUATION

INTRODUCTION

• HISTORY• INSPECTION• PALPATION• ROM TEST• STRESS/SPECIAL TESTS• NEUROLOGIC TEST• VASCULAR TEST

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HISTORY

• Location of Pain• Mechanism of Injury• Weight-Bearing Status• Associated Sounds or Sensations• Onset of Injury• Prior History of Injury

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Location of Pain

• Collateral ligament injury - pain localized to traumatized area

• Cruciate ligament injury - pain noted “inside” knee/under kneecap

• Meniscal injury - pain at joint line, or reported at “popping/clicking/snapping”

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Mechanism of Injury

• Straight plane force application typically results in isolated ligament injuries

• Rotational forces typically injury multiple ligamentous structures and/or meniscal tissue

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Weight-Bearing Status

• Rotational injuries may further be identified by establishing the weight-bearing status of the involved limb

• For example, a foot was planted at the time of injury fixates the tibia, allowing the femur to rotate on it

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Associated Sounds or Sensations

• “Pop/snap” may be associated with patellar subluxation/dislocation, fractures, cruciate ligament injury

• “Locking/clicking” may be associated with loose bodies and/or meniscal injury

• “Giving way” may be associated with multiple ligamentous injury and/or PF joint injury

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Onset of Injury

• Acute onset - ligamentous/meniscal injury with associated specific MOI

• Insidious onset - muscle/tendon injuries, PF tracking abnormalities, can be secondary to biomechanical, training and/or equipment insufficiencies

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Prior History of Injury

• Prior ligamentous injury not treated surgically may have significant scar and/or laxity which can impact ROM and joint stability

• Surgical interventions subject to reinjury• Chronic inflammatory conditions can present

due to prior injury - OA

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INSPECTION• Girth Measurements• (Inspection of the) Anterior Structures• (Inspection of the) Lateral Structures• (Inspection of the) Posterior Structures• (Inspection of the) Medial Structures

• Leg Length

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Girth Measurements• Determination of the amount of swelling• Atrophy of the quadriceps muscle groups• Around the joint line (0 in.) 2-inch

increments (0, 2, 4, and 6 inches)

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Anterior Structures

• Patellar Subluxation or Dislocation• Patellar Alignment• Q Angle• Patellar Tendon Rupture/Prepatellar Bursitis• Genu Varum/Genu Valgum• Osgood-Schlatter/Larsen Johansson

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• Patellar Subluxation or Dislocation

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• Alignment of Patellar– Patella alta – high riding

patella– Patella baja – low riding

patella– Increased risk of PF

joint degenerative conditions

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• Q Angle– Line from ASIS to mid-

superior patella– Line from mid-patella to

tibial tuberosity– Angle between lines is Q

angle– Normal

• Male = 13˚ • Female = 18˚

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• Prepatellar Bursitis

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• Patellar Tendon Rupture

Alignment of the Tibia on the Femur

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NormalGenu Varum

=Bow Legged

Genu Valgum=

Knock Knees

Genu Recurvatum

• Osgood-Schlatter’s disease at tibial tuberosity

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Lateral Structures• Genu recurvatum –

hyperextension of tibiofemoral joint

• Posterior sag of proximal tibia – PCL injury

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Posterior Structures

• Popliteal fossa

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• Baker’s cyst (Popliteal cyst)

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Leg Length

• True (Structural) vs. Apparent (Functional)

• True = actual difference in length of tibia and/or femur one side vs. the other

• Apparent = no true length difference but apparent one due to muscle weakness and/or tightness or imbalance

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PALPATION (Anterior Structures)

1. Patellar2. Patellar tendon3. Tibial tuberosity4. Quadriceps tendon5-8. Quadriceps muscle group9. Sartorius

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PALPATION (Medial Structures)

1. Medial meniscus and joint line2. Medial collateral ligament3. Medial femoral condyle and

epicondyle4. Medial tibial plateau5. Pes anserine tendon and bursa6. Semitendinosus tendon7. Gracilis

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PALPATION (Lateral Structures)

1. Joint line2. Fibular head3. Lateral collateral ligament4. Popliteus5. Biceps femoris6. Iliotibial (IT) band7. Gerdy’s tubercle

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PALPATION (Posterior Structures)

1. Popliteal fossa2. Biceps femoris3. Semimembranosus4. Semitendinosus5. Ischial tuberosity6-7. Heads of the gastrocnemius

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RANGE OF MOTION TEST

Active ROM

• Flexion and extension– 135 to 145 degrees with the majority of the

motion occurring as flexion– Genu recurvatum (as great as 10˚ beyond 0˚)– Flexion limited by

• Tightness of the quadriceps group, especially rectus femoris

• Fully extended hip can limit the amount of flexion available at the knee

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• Internal and external rotation– Observe and bilaterally compare the rotation of

the tibial tuberosity to estimate the amount of internal and external rotation that occurs during active knee flexion and extension

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Passive ROM• Flexion

– Measured with the patient lying supine to remove the influence of excessive rectus femoris tightness

– Measured in the prone position with the rectus femoris stretched over the hip and knee joints more closely reflects the affect of muscular tightness on the joint

– “Soft” end-feel: approximation of the gastrocnemius group with the hamstrings of the heel striking the buttock

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• Extension– Measured with the tibia slightly elevated by placing

a bolster under the distal tibia with the patient in the supine position

– “Firm” end feel: the posterior capsule and the cruciate ligaments stretch

– Tightness of hamstring group may limit extension• Immobilization• Flexion contracture• Swelling• Stiffness

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Goniometry

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Resisted ROM• Flexion

– Measured in prone and the knee is extended– Isometric break test may be applied

• 10, 45, and 90˚

• Extension– Measured in seated with the knee flexed– Isometric break tests may be applied with the

knee flexed to• 15, 45, 90, and 120˚

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• Excessive internal rotation indicates– Biceps femoris weakness

• Excessive external rotation indicates– Semimembranosus or semitendinosus pathology

(or both)

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STRESS TESTS

• Ligamentous Stress Tests– ACL– PCL– MCL– LCL– Proximal Tibiofibular Ligaments

• Meniscal Tests

• Patellar Tests

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ACL TESTS

• Anterior Drawer Test• Slocum Tests

• Lachman’s Test• Modified Lachman• Alternate Lachman

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Anterior Drawer/Slocum Tests

• Drawer test at 90˚ of knee flexion– Tibia sliding forward from under the femur

is considered a positive sign (ACL)

– Performed w/ knee internally and externally to test integrity of joint capsule

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Lachman’s Tests

• Will not force knee into painful flexion immediately after injury

• Reduces hamstring involvement• At 20-30˚ of flexion an attempt is made to

translate the tibia anteriorly on the femur• A positive test indicates damage to the ACL

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Instrument Assessment of the Cruciate Ligaments

• A number of devices are available to quantify AP displacement of the knee

• KT-2000 arthrometer, Stryker knee laxity tester and Genucom can be used to assess the knee

• Test can be taken pre & post-operatively and through rehab

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ROTATIONAL INSTABILITY TESTS

• Pivot Shift Test• Crossover Test

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Pivot Shift Test• Used to determine anterolateral rotary

instability• Position starts w/ knee extended and leg

internally rotated• The thigh and knee are then flexed w/ a

valgus stress applied to the knee• Reduction of the tibial plateau (producing a

clunk) is a positive sign

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Crossover Test• ALRI

– Patients step across and in front with the uninvolved leg– Rotate the torso in direction with movement– Weight bearing foot remains fixed– Instability of the lateral capsular

• AMRI– Patients step across and behind with the uninvolved leg– Rotate the torso in direction with movement– Weight bearing foot remains fixed– Instability of the medial capsular

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ALRI AMRI

PCL TESTS

• Posterior Drawer Test• Godfrey’s Test (Posterior Sag Test)

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Godfrey’s Test

• Athlete is supine w/ both knees flexed to 90˚

• Lateral observation is required to determine extent of posterior sag while comparing bilaterally

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MCL/LCL TESTS• Used to assess the integrity of the MCL (Varus

Test) and LCL (Valgus Test) respectively. Testing at 0˚ incorporates capsular testing while testing at 30˚ of flexion isolates the ligaments

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Varus Test Valgus Test

PROXIMAL TIBIOFIBULAR LIGAMENTS

• Lying supine with the knee 90˚ flexion• One hand stabilize the tibia• The other hand grasps the fibular head• Attempts to displace the fibular head

anteriorly and then posteriorly

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MENISCAL TESTS

• McMurray’s Test• Apley’s Compression Test• Apley’s Distraction Test

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McMurray’s Test

• Used to determine displaceable meniscal tear• Leg is moved into flexion and extension while

knee is internally and externally rotated in conjunction w/ valgus and varus stressing

• A positive test is found w/ clicking and popping response

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• Apley’s Compression Test– Hard downward pressure is

applied w/ rotation– Pain indicates a meniscal

injury

• Apley’s Distraction Test– Traction is applied w/

rotation– Pain will occur if there is

damage to the capsule or ligaments

– No pain will occur if it is meniscal

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PATELLAR TESTS

• Patellar Apprehension Test• Patellar Grind Test (Clarke’s Sign)

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Apprehension Test

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Patellar Grind Test

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NEUROLOGICAL TESTS

• L3 Nerve Root– Dermatome – anterior and medial thigh– Myotome – knee extension

• Femoral nerve– Dermatome – (anterior thigh)– Myotome – knee extension

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VASCULAR TEST

• Popliteal artery – difficult to palpate pulse– Terminates as

anterior and posterior tibial arteries, so can assess at distal pulse points

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