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Presentation on theme: "KNEE EVALUATIONS."— Presentation transcript:



3 The Knee Joint Knee joint proper (tibiofemoral joint)
Tibia Fibula Femur Patella Patellofemoral joint Femoral condyles articulate with tibial plateaus

4 The Knee Joint Extends to 180º Flexes to 140º
Hyperextension normal Flexes to 140º With knee flexed 30º or > internal rotation 30º occurs external rotation 45º occurs

5 The Patella Sesamoid bone Imbedded in quadriceps & patella tendon
Serves similar to a pulley for improving angle of pull (results in greater mechanical advantage in knee extension)

6 Surface Anatomy Patella (A) Femur (B) Tibia (C, E – tuberosity)
Joint Line (D) Fibula (F) Gerdy’s Tubercle

7 Internal Knee Anatomy

8 Internal Knee Anatomy

9 Menisci

10 Bursae & Fat Pad of the Knee

11 Housemaid’s knee

12 Anatomy – Soft Tissue Quadriceps – Hamstrings – Popliteal fossa
Rectus femoris Vastus lateralis Vastus intermedius Vastus medialis (& oblique - VMO) Hamstrings – Biceps femoris Inserts primarily on fibula head Semitendinosus Semimembranosus Inserts posteromedially on medial tibial condyle Popliteal fossa

13 Muscles Gracilis, Sartorius & Semitendinosus Iliotibial Band
Common attachment Pes Anscerine Iliotibial Band Gastrocnemius heads – lateral & medial

14 Knee Movements

15 Screw Home Mechanism Locking mechanism as the knee nears its final extension degrees Automatic rotation of the tibia externally (approx. 10 degrees) during the last 20 degrees of knee extension Femoral condyles are a different size Medial has larger surface area The tibia glides anteriorly on the femur. As knee extends, the lateral femoral condyle expends its articular distance. The medial articulation continues to glide, resulting in external rotation of the tibia utilizing the lateral meniscus as the pivot point. ACL & PCL are rotary guides Forms a close-packed position for the knee joint

16 History MOI - Previous history Pain (levels, types, descriptors)
Position of lower extremity at time of injury (?foot planted, knee extended) Previous history Pain (levels, types, descriptors) Unusual sounds/sensations “pop, clicking, snapping” Chronic vs. acute Location of pain “inside the knee” Surface Shoes Type of activity at time of injury Painful to walk up/down stairs; any clicking, catching Did it swell immediately, slowly? Is the swelling located in the knee or in a pocket?

17 Observation Bilateral comparison
Gait (limp, walking on toes, do they not want to extend knee, do they keep the knee stiff) Swelling (girth measurements) Discoloration Deformity (squinting patellae, “Frog-eyed” patellae, Patella alta, Patella baja) Genu valgum, genu varum, recurvatum Musculature – defined/mushy

18 Q-angle The quadriceps angle (Q-angle) is the angle formed between a line drawn through the tibial tuberosity and the center of the patella and another line drawn from the anterior superior iliac spine (ASIS) of the pelvis through the center of the patella.


20 Palpation Tibia – tibial plateau, tibial tuberosity, Gerdy’s Tubercle
Fibula – head Medial joint line Medial collateral ligament Lateral joint line Lateral collateral ligament “Windows” Medial & Lateral femoral condyles & epicondyles Pes anserine tendon Semitendinosus tendon Patella – inferior pole Patellar tendon Quadriceps muscle group Biceps femoris tendon Iliotibial band Popliteal fossa Gastrocnemius heads

21 Stress/Special Tests On-field vs. Off-field eval
Check for fractures, blood, deformities, neurological Valgus Stress Test – MCL Varus Stress Test - LCL Lachman’s – ACL Anterior Drawer – ACL McMurray’s - meniscus

22 Anterior Drawer Test (+) Test is increased anterior tibial translation over 6 mm (+) test indicates: ACL (anteromedial bundle) posterior lateral capsule posterior medial capsule MCL (deep fibers) ITB Arcuate complex False (-) if only ACL is torn False (-) if there is swelling or hamstring spasm False (+) if there is a posterior sag sign present

23 Lachman’s Test Best acute ACL test Best on field test
(+) test is a “mushy” or “empty” end-feel False (-) if tibia is IR or femur is not properly stabilized

24 Posterior Drawer Test Tests for posterior instability
Make sure that there is no anterior translation prior to performing test (+) Test indicates: PCL Arcuate Complex Possibly ACL ??? Rubenstein, et al 1994 found posterior drawer test 90% sensitive for PCL injury (versus 58% for Quadriceps Active Test & 26% for Reverse Pivot Shift Test). Clinical exam on whole was 96% effective in detecting PCL dysfunction

25 Godfrey’s Test Tests for posterior cruciate ligament damage
(+) test is a posterior displacement of the tibial tuberosity

26 Valgus Stress Test (+) Test in 30° Grading Sprains
Assesses medial instability Must be tested in 0° and 30° (+) Test in 0° MCL (superficial and deep) Posterior oblique ligament Posterior medial capsule ACL/PCL (+) Test in 30° MCL (superficial) PCL Grading Sprains Miller et al 1998 used MRI to evaluate 65 patients with Grade III MCL sprains & found 45% also suffered bone bruising or microfracture. Bone injury with Grade III MCL is 50% as common as with Grade III ACL. McClure et al 1989 found poor intertester reliability on valgus stress test at 0 and 30 degrees using 3 PT to evaluate 50 patients

27 Varus Stress Test Assesses lateral instability
Must be tested in 0° and 20/30° flexion (+) Test in 0° LCL Posterior Lateral Capsule Arcuate Complex PCL/ACL (+) Test in 30° Posterior lateral capsule Arcuate complex Grading Sprains

28 Apley’s Distraction Test
Tests for meniscal or ligamentous lesions (+) test is pain that is eliminated (meniscal injury), or pain that is increased (ligamentous)

29 Apley’s Compression Test
Tests for meniscal lesions (+) test is increased pain during compression which may increase with rotation in either direction

30 Stress/Special Tests Check for swelling Check ROM Ely’s Test
Sweep Test, Ballotable Patella Check ROM Ely’s Test Check integrity of ligaments & joint stability Valgus, Varus, Lachman’s, Anterior/Posterior Drawer, Godfrey’s Test, Posterior Sag Test, Crossover Test, Slocum Drawer Test, External Rotation Test, Pivot Shift Check integrity of meniscus McMurray’s, Apley’s Compression/Distraction, Duck Walk, Bounce home Check integrity of patella Patellar Apprehension, Q Angle, Clarke’s Sign, Patellar glide, tilt, rotation Check integrity of Iliotibial Band Ober’s Test, Noble’s Compression Test

31 Now What? ? Crutches ? Referral ? RICE

32 Osgood-Schlatter’s Disease

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