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Kin191 A.Ch.6.Knee.Patellofemoral.Evaluation
 

Kin191 A.Ch.6.Knee.Patellofemoral.Evaluation

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Kin191 A.Ch.6.Knee.Patellofemoral.Evaluation Kin191 A.Ch.6.Knee.Patellofemoral.Evaluation Presentation Transcript

  • KIN 191A Advanced Assessment of Lower Extremity Injuries KNEE /PATELLOFEMORALARTICULATION EVALUATION
  • INTRODUCTION
    • HISTORY
    • INSPECTION
    • PALPATION
    • ROM TEST
    • STRESS/SPECIAL TEST S
    • NEUROLOGIC TEST
    • VASCULAR TEST
  • HISTORY
    • Location of Pain
    • Mechanism of Injury
    • Weight-Bearing Status
    • Associated Sounds or Sensations
    • Onset of Injury
    • Prior History of Injury
  • 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”
  • Mechanism of Injury
    • Straight plane force application typically results in isolated ligament injuries
    • Rotational forces typically injury multiple ligamentous structures and/or meniscal tissue
  • 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
  • Associated Sounds or Sensations
    • “ P op/snap” may be associated with patellar subluxation/dislocation, fractures, cruciate ligament injury
    • “ L ocking/clicking” may be associated with loose bodies and/or meniscal injury
    • “ G iving way” may be associated with multiple ligamentous injury and/or PF joint injury
  • Onset of Injury
    • Acute onset - ligamentous/meniscal injury with associated specific MOI
    • Insid i ous onset - muscle/tendon injuries, PF tracking abnormalities, can be secondary to biomechanical, training and/or equipment insufficiencies
  • Prior H istory of I njury
    • 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
  • 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
  • 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)
  • Anterior Structures
    • Patellar Subluxation or Dislocation
    • Patellar Alignment
    • Q Angle
    • Patellar Tendon Rupture/Prepatellar Bursitis
    • Genu Varum/Genu Valgum
    • Osgood-Schlatter/Larsen Johansson
    • Patellar Subluxation or Dislocation
    • Alignment of Patellar
      • Patella alta – high riding patella
      • Patella baja – low riding patella
      • Increased risk of PF joint degenerative conditions
    • Q A ngle
      • Line from ASIS to mid-superior patella
      • Line from mid-patella to tibial tuberosity
      • Angle between lines is Q angle
      • Normal
        • M ale = 13 ˚
        • F emale = 18 ˚
    • Prep atellar Bursitis
    • Patellar T endon R upture
  • Alignment of the Tibia on the Femur Normal Genu Varum = Bow Legged Genu Valgum = Knock Knees Genu Recurvatum
    • Osgood-Schlatter’s disease at tibial tuberosity
  • Lateral Structures
    • Genu recurvatum – hyperextension of tibiofemoral joint
    • Posterior sag of proximal tibia – PCL injury
  • Posterior Structures
    • Popliteal fossa
    • Baker’s cyst (Popliteal cyst)
  • Leg Length
    • True (Structural) vs. A pparent (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
  • PALPATION (Anterior Structures)
    • Patellar
    • Patellar tendon
    • Tibial tuberosity
    • Quadriceps tendon
    • 5-8. Quadriceps muscle
    • group
    • 9. Sartorius
  • PALPATION (Medial Structures)
    • Medial meniscus and joint line
    • Medial collateral ligament
    • Medial femoral condyle and epicondyle
    • Medial tibial plateau
    • Pes anserine tendon and bursa
    • Semitendinosus tendon
    • Gracilis
  • PALPATION (Lateral Structures)
    • Joint line
    • Fibular head
    • Lateral collateral ligament
    • Popliteus
    • Biceps femoris
    • Iliotibial (IT) band
    • Gerdy’s tubercle
  • PALPATION (Posterior Structures)
    • 1. Popliteal fossa
    • 2. Biceps femoris
    • 3. Semimembranosus
    • 4. Semitendinosus
    • 5. Ischial tuberosity
    • 6-7. Heads of the gastrocnemius
  • 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
    • 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
  • 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
    • 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
  • Goniometry
  • 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˚
    • Excessive internal rotation indicates
      • Biceps femoris weakness
    • Excessive external rotation indicates
      • Semimembranosus or semitendinosus pathology (or both)
  • STRESS TESTS
    • Ligamentous Stress Tests
      • ACL
      • PCL
      • MCL
      • LCL
      • Proximal Tibiofibular Ligaments
    • Meniscal Tests
    • Patellar Tests
  • ACL TESTS
    • Anterior Drawer Test
    • Slocum Tests
    • Lachman’s Test
    • Modified Lachman
    • Alternate Lachman
  • Anterior Drawer/Slocum Tests
    • Drawer test at 90 ˚ of knee flexion
      • Tibia sliding forward from under the femur is considered a positive sign (ACL)
      • P erformed w/ knee internally and externally to test integrity of joint capsule
  • 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
  • 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
  • ROTATIONAL INSTABILITY TESTS
    • Pivot Shift Test
    • Crossover Test
  • 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
  • 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
  • ALRI AMRI
  • PCL TESTS
    • Posterior Drawer Test
    • Godfrey’s Test (Posterior Sag Test)
  • 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
  • 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
    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
  • MENISCAL TESTS
    • McMurray’s Test
    • Apley’s Compression Test
    • Apley’s Distraction Test
  • 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
    • 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
  • PATELLAR TESTS
    • Patellar Apprehension Test
    • Patellar Grind Test (Clarke’s Sign)
  • Apprehension Test
  • Patellar Grind Test
  • N EUROLOGICAL T ESTS
    • L3 Nerve Root
      • D ermatome – anterior and medial thigh
      • M yotome – knee extension
    • Femoral nerve
      • Dermatome – ( anterior thigh )
      • M yotome – knee extension
  • V ASCULAR T EST
    • Popliteal artery – difficult to palpate pulse
      • Terminates as anterior and posterior tibial arteries, so can assess at distal pulse points