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


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

    1. 1. KIN 191A Advanced Assessment of Lower Extremity Injuries KNEE /PATELLOFEMORALARTICULATION EVALUATION
    2. 2. INTRODUCTION <ul><li>HISTORY </li></ul><ul><li>INSPECTION </li></ul><ul><li>PALPATION </li></ul><ul><li>ROM TEST </li></ul><ul><li>STRESS/SPECIAL TEST S </li></ul><ul><li>NEUROLOGIC TEST </li></ul><ul><li>VASCULAR TEST </li></ul>
    3. 3. HISTORY <ul><li>Location of Pain </li></ul><ul><li>Mechanism of Injury </li></ul><ul><li>Weight-Bearing Status </li></ul><ul><li>Associated Sounds or Sensations </li></ul><ul><li>Onset of Injury </li></ul><ul><li>Prior History of Injury </li></ul>
    4. 4. Location of Pain <ul><li>Collateral ligament injury - pain localized to traumatized area </li></ul><ul><li>Cruciate ligament injury - pain noted “inside” knee/under kneecap </li></ul><ul><li>Meniscal injury - pain at joint line, or reported at “popping/clicking/snapping” </li></ul>
    5. 5. Mechanism of Injury <ul><li>Straight plane force application typically results in isolated ligament injuries </li></ul><ul><li>Rotational forces typically injury multiple ligamentous structures and/or meniscal tissue </li></ul>
    6. 6. Weight-Bearing Status <ul><li>Rotational injuries may further be identified by establishing the weight-bearing status of the involved limb </li></ul><ul><li>For example, a foot was planted at the time of injury fixates the tibia, allowing the femur to rotate on it </li></ul>
    7. 7. Associated Sounds or Sensations <ul><li>“ P op/snap” may be associated with patellar subluxation/dislocation, fractures, cruciate ligament injury </li></ul><ul><li>“ L ocking/clicking” may be associated with loose bodies and/or meniscal injury </li></ul><ul><li>“ G iving way” may be associated with multiple ligamentous injury and/or PF joint injury </li></ul>
    8. 8. Onset of Injury <ul><li>Acute onset - ligamentous/meniscal injury with associated specific MOI </li></ul><ul><li>Insid i ous onset - muscle/tendon injuries, PF tracking abnormalities, can be secondary to biomechanical, training and/or equipment insufficiencies </li></ul>
    9. 9. Prior H istory of I njury <ul><li>Prior ligamentous injury not treated surgically may have significant scar and/or laxity which can impact ROM and joint stability </li></ul><ul><li>Surgical interventions subject to reinjury </li></ul><ul><li>Chronic inflammatory conditions can present due to prior injury - OA </li></ul>
    10. 10. INSPECTION <ul><li>Girth Measurements </li></ul><ul><li>(Inspection of the) Anterior Structures </li></ul><ul><li>(Inspection of the) Lateral Structures </li></ul><ul><li>(Inspection of the) Posterior Structures </li></ul><ul><li>(Inspection of the) Medial Structures </li></ul><ul><li>Leg Length </li></ul>
    11. 11. Girth Measurements <ul><li>Determination of the amount of swelling </li></ul><ul><li>Atrophy of the quadriceps muscle groups </li></ul><ul><li>Around the joint line (0 in.)  2-inch increments (0, 2, 4, and 6 inches) </li></ul>
    12. 12. Anterior Structures <ul><li>Patellar Subluxation or Dislocation </li></ul><ul><li>Patellar Alignment </li></ul><ul><li>Q Angle </li></ul><ul><li>Patellar Tendon Rupture/Prepatellar Bursitis </li></ul><ul><li>Genu Varum/Genu Valgum </li></ul><ul><li>Osgood-Schlatter/Larsen Johansson </li></ul>
    13. 13. <ul><li>Patellar Subluxation or Dislocation </li></ul>
    14. 14. <ul><li>Alignment of Patellar </li></ul><ul><ul><li>Patella alta – high riding patella </li></ul></ul><ul><ul><li>Patella baja – low riding patella </li></ul></ul><ul><ul><li>Increased risk of PF joint degenerative conditions </li></ul></ul>
    15. 15. <ul><li>Q A ngle </li></ul><ul><ul><li>Line from ASIS to mid-superior patella </li></ul></ul><ul><ul><li>Line from mid-patella to tibial tuberosity </li></ul></ul><ul><ul><li>Angle between lines is Q angle </li></ul></ul><ul><ul><li>Normal </li></ul></ul><ul><ul><ul><li>M ale = 13 ˚ </li></ul></ul></ul><ul><ul><ul><li>F emale = 18 ˚ </li></ul></ul></ul>
    16. 16. <ul><li>Prep atellar Bursitis </li></ul><ul><li>Patellar T endon R upture </li></ul>
    17. 17. Alignment of the Tibia on the Femur Normal Genu Varum = Bow Legged Genu Valgum = Knock Knees Genu Recurvatum
    18. 18. <ul><li>Osgood-Schlatter’s disease at tibial tuberosity </li></ul>
    19. 19. Lateral Structures <ul><li>Genu recurvatum – hyperextension of tibiofemoral joint </li></ul><ul><li>Posterior sag of proximal tibia – PCL injury </li></ul>
    20. 20. Posterior Structures <ul><li>Popliteal fossa </li></ul>
    21. 21. <ul><li>Baker’s cyst (Popliteal cyst) </li></ul>
    22. 22. Leg Length <ul><li>True (Structural) vs. A pparent (Functional) </li></ul><ul><li>True = actual difference in length of tibia and/or femur one side vs. the other </li></ul><ul><li>Apparent = no true length difference but apparent one due to muscle weakness and/or tightness or imbalance </li></ul>
    23. 23. PALPATION (Anterior Structures) <ul><li>Patellar </li></ul><ul><li>Patellar tendon </li></ul><ul><li>Tibial tuberosity </li></ul><ul><li>Quadriceps tendon </li></ul><ul><li>5-8. Quadriceps muscle </li></ul><ul><li>group </li></ul><ul><li>9. Sartorius </li></ul>
    24. 24. PALPATION (Medial Structures) <ul><li>Medial meniscus and joint line </li></ul><ul><li>Medial collateral ligament </li></ul><ul><li>Medial femoral condyle and epicondyle </li></ul><ul><li>Medial tibial plateau </li></ul><ul><li>Pes anserine tendon and bursa </li></ul><ul><li>Semitendinosus tendon </li></ul><ul><li>Gracilis </li></ul>
    25. 25. PALPATION (Lateral Structures) <ul><li>Joint line </li></ul><ul><li>Fibular head </li></ul><ul><li>Lateral collateral ligament </li></ul><ul><li>Popliteus </li></ul><ul><li>Biceps femoris </li></ul><ul><li>Iliotibial (IT) band </li></ul><ul><li>Gerdy’s tubercle </li></ul>
    26. 26. PALPATION (Posterior Structures) <ul><li>1. Popliteal fossa </li></ul><ul><li>2. Biceps femoris </li></ul><ul><li>3. Semimembranosus </li></ul><ul><li>4. Semitendinosus </li></ul><ul><li>5. Ischial tuberosity </li></ul><ul><li>6-7. Heads of the gastrocnemius </li></ul>
    28. 28. Active ROM <ul><li>Flexion and extension </li></ul><ul><ul><li>135 to 145 degrees with the majority of the motion occurring as flexion </li></ul></ul><ul><ul><li>Genu recurvatum (as great as 10˚ beyond 0˚) </li></ul></ul><ul><ul><li>Flexion limited by </li></ul></ul><ul><ul><ul><li>Tightness of the quadriceps group, especially rectus femoris </li></ul></ul></ul><ul><ul><ul><li>Fully extended hip can limit the amount of flexion available at the knee </li></ul></ul></ul>
    29. 29. <ul><li>Internal and external rotation </li></ul><ul><ul><li>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 </li></ul></ul>
    30. 30. Passive ROM <ul><li>Flexion </li></ul><ul><ul><li>Measured with the patient lying supine to remove the influence of excessive rectus femoris tightness </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>“ Soft” end-feel: approximation of the gastrocnemius group with the hamstrings of the heel striking the buttock </li></ul></ul>
    31. 31. <ul><li>Extension </li></ul><ul><ul><li>Measured with the tibia slightly elevated by placing a bolster under the distal tibia with the patient in the supine position </li></ul></ul><ul><ul><li>“ Firm” end feel: the posterior capsule and the cruciate ligaments stretch </li></ul></ul><ul><ul><li>Tightness of hamstring group may limit extension </li></ul></ul><ul><ul><ul><li>Immobilization </li></ul></ul></ul><ul><ul><ul><li>Flexion contracture </li></ul></ul></ul><ul><ul><ul><li>Swelling </li></ul></ul></ul><ul><ul><ul><li>Stiffness </li></ul></ul></ul>
    32. 32. Goniometry
    33. 33. Resisted ROM <ul><li>Flexion </li></ul><ul><ul><li>Measured in prone and the knee is extended </li></ul></ul><ul><ul><li>Isometric break test may be applied </li></ul></ul><ul><ul><ul><li>10, 45, and 90˚ </li></ul></ul></ul><ul><li>Extension </li></ul><ul><ul><li>Measured in seated with the knee flexed </li></ul></ul><ul><ul><li>Isometric break tests may be applied with the knee flexed to </li></ul></ul><ul><ul><ul><li>15, 45, 90, and 120˚ </li></ul></ul></ul>
    34. 34. <ul><li>Excessive internal rotation indicates </li></ul><ul><ul><li>Biceps femoris weakness </li></ul></ul><ul><li>Excessive external rotation indicates </li></ul><ul><ul><li>Semimembranosus or semitendinosus pathology (or both) </li></ul></ul>
    35. 35. STRESS TESTS <ul><li>Ligamentous Stress Tests </li></ul><ul><ul><li>ACL </li></ul></ul><ul><ul><li>PCL </li></ul></ul><ul><ul><li>MCL </li></ul></ul><ul><ul><li>LCL </li></ul></ul><ul><ul><li>Proximal Tibiofibular Ligaments </li></ul></ul><ul><li>Meniscal Tests </li></ul><ul><li>Patellar Tests </li></ul>
    36. 36. ACL TESTS <ul><li>Anterior Drawer Test </li></ul><ul><li>Slocum Tests </li></ul><ul><li>Lachman’s Test </li></ul><ul><li>Modified Lachman </li></ul><ul><li>Alternate Lachman </li></ul>
    37. 37. Anterior Drawer/Slocum Tests <ul><li>Drawer test at 90 ˚ of knee flexion </li></ul><ul><ul><li>Tibia sliding forward from under the femur is considered a positive sign (ACL) </li></ul></ul><ul><ul><li>P erformed w/ knee internally and externally to test integrity of joint capsule </li></ul></ul>
    38. 38.
    39. 39. Lachman’s Tests <ul><li>Will not force knee into painful flexion immediately after injury </li></ul><ul><li>Reduces hamstring involvement </li></ul><ul><li>At 20- 30 ˚ of flexion an attempt is made to translate the tibia anteriorly on the femur </li></ul><ul><li>A positive test indicates damage to the ACL </li></ul>
    40. 40.
    41. 41.
    42. 42. Instrument Assessment of the Cruciate Ligaments <ul><li>A number of devices are available to quantify AP displacement of the knee </li></ul><ul><li>KT-2000 arthrometer, Stryker knee laxity tester and Genucom can be used to assess the knee </li></ul><ul><li>Test can be taken pre & post-operatively and through rehab </li></ul>
    43. 43. ROTATIONAL INSTABILITY TESTS <ul><li>Pivot Shift Test </li></ul><ul><li>Crossover Test </li></ul>
    44. 44. Pivot Shift Test <ul><li>Used to determine anterolateral rotary instability </li></ul><ul><li>Position starts w/ knee extended and leg internally rotated </li></ul><ul><li>The thigh and knee are then flexed w/ a valgus stress applied to the knee </li></ul><ul><li>Reduction of the tibial plateau (producing a clunk) is a positive sign </li></ul>
    45. 45.
    46. 46. Crossover Test <ul><li>ALRI </li></ul><ul><ul><li>Patients step across and in front with the uninvolved leg </li></ul></ul><ul><ul><li>Rotate the torso in direction with movement </li></ul></ul><ul><ul><li>Weight bearing foot remains fixed </li></ul></ul><ul><ul><li>Instability of the lateral capsular </li></ul></ul><ul><li>AMRI </li></ul><ul><ul><li>Patients step across and behind with the uninvolved leg </li></ul></ul><ul><ul><li>Rotate the torso in direction with movement </li></ul></ul><ul><ul><li>Weight bearing foot remains fixed </li></ul></ul><ul><ul><li>Instability of the medial capsular </li></ul></ul>
    47. 47. ALRI AMRI
    48. 48. PCL TESTS <ul><li>Posterior Drawer Test </li></ul><ul><li>Godfrey’s Test (Posterior Sag Test) </li></ul>
    49. 49. Godfrey’s Test <ul><li>Athlete is supine w/ both knees flexed to 90 ˚ </li></ul><ul><li>Lateral observation is required to determine extent of posterior sag while comparing bilaterally </li></ul>
    50. 50. MCL/LCL TESTS <ul><li>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 </li></ul>Varus Test Valgus Test
    51. 51. PROXIMAL TIBIOFIBULAR LIGAMENTS <ul><li>Lying supine with the knee 90˚ flexion </li></ul><ul><li>One hand stabilize the tibia </li></ul><ul><li>The other hand grasps the fibular head </li></ul><ul><li>Attempts to displace the fibular head anteriorly and then posteriorly </li></ul>
    52. 52. MENISCAL TESTS <ul><li>McMurray’s Test </li></ul><ul><li>Apley’s Compression Test </li></ul><ul><li>Apley’s Distraction Test </li></ul>
    53. 53. McMurray’s Test <ul><li>Used to determine displaceable meniscal tear </li></ul><ul><li>Leg is moved into flexion and extension while knee is internally and externally rotated in conjunction w/ valgus and varus stressing </li></ul><ul><li>A positive test is found w/ clicking and popping response </li></ul>
    54. 54.
    55. 55. <ul><li>Apley’s Compression Test </li></ul><ul><ul><li>Hard downward pressure is applied w/ rotation </li></ul></ul><ul><ul><li>Pain indicates a meniscal injury </li></ul></ul><ul><li>Apley’s Distraction Test </li></ul><ul><ul><li>Traction is applied w/ rotation </li></ul></ul><ul><ul><li>Pain will occur if there is damage to the capsule or ligaments </li></ul></ul><ul><ul><li>No pain will occur if it is meniscal </li></ul></ul>
    56. 56. PATELLAR TESTS <ul><li>Patellar Apprehension Test </li></ul><ul><li>Patellar Grind Test (Clarke’s Sign) </li></ul>
    57. 57. Apprehension Test
    58. 58. Patellar Grind Test
    59. 59. N EUROLOGICAL T ESTS <ul><li>L3 Nerve Root </li></ul><ul><ul><li>D ermatome – anterior and medial thigh </li></ul></ul><ul><ul><li>M yotome – knee extension </li></ul></ul><ul><li>Femoral nerve </li></ul><ul><ul><li>Dermatome – ( anterior thigh ) </li></ul></ul><ul><ul><li>M yotome – knee extension </li></ul></ul>
    60. 60. V ASCULAR T EST <ul><li>Popliteal artery – difficult to palpate pulse </li></ul><ul><ul><li>Terminates as anterior and posterior tibial arteries, so can assess at distal pulse points </li></ul></ul>