Rick- Knee & Lower Leg

Front 1

Show the following landmarks for the knee and lower leg region and give the soft tissues (muscle, tendon, ligaments) attached:

Back 1

a) Tibial tuberosity
b) Inferior pole of patella
c) Superior pole of patella
d) Patella tendon
e) Quadriceps tendon
f) Fibula head
g) Tibiofibular joint
h) Common fibular (peroneal) nerve
i) Popliteal artery
j) Lateral collateral ligament
k) Medial collateral ligament
l) Pes anserinus bursa and tendons
m) Site of bursa complex around knee
n) Femoral condyles
o) Tibial plateaus and joint space - anterior, medial and lateral
p) Adductor tubercle
q) Semimembranosis tendon and muscle
r) Semitendinosus tendon and muscle
s) Sartorius tendon and muscle
t) Gracilis tendon and muscle
u) Biceps femoris tendon and muscle
v) Gastrocnemius tendons
w) Vastus medialis muscle
x) Vastus lateralis muscle
y) Rectus femoris muscle
z) Vastus intermedius muscle
aa) Iliotibial band insertions

Front 2

Tibiofemoral joint
long axis distraction

Back 2

Front 3

A-P/P-A glide (90o flexion)

Back 3

Front 4

A-P/P-A glide extension

Back 4

Front 5

Internal/external rotation (90o flexion)

Back 5

Front 6

Internal/external rotation (extension)

Back 6

Front 7

M-L/L-M glide (extension)

Back 7

Front 8

Tibiofibular: (Proximal)
A-P/P-A glide (90o flexion)

Back 8

Front 9

A-P/P-A glide (extension)

Back 9

Front 10

S-I/I-S glide (90o flexion)

Back 10

Front 11

S-I/I-S glide (extension)

Back 11

Front 12

Patellofemoral:
I-S/S-I glide

Back 12

Front 13

M-L/L-M glide

Back 13

Front 14

clockwise/counterclockwise rotation

Back 14

Front 15

Rectus femoris

Back 15

Front 16

Quadriceps group

Back 16

Front 17

Adductors

Back 17

Front 18

Sartorius

Back 18

Front 19

Tensor fascia lata

Back 19

Front 20

Popliteus

Back 20

T.P.: Prone, knee flexed 90º, tibia medially rotated on femur.
TEST: Attempt to rotate tibia laterally on femur.
OBS: Knee flexion or extension, rotation of femur at hip.

Front 21

Hamstring group

Back 21

Front 22

Lateral hamstring
Medial hamstring

Back 22

Front 23

Gracilis

Back 23

Pressure is directed against the posterior medial aspect of the distal leg in a direction of knee extension and slightly lateral. Thigh must be kept in position of extension and abduction.

Front 24

General Ortho tests
Bounce Home test

Back 24

Flex knee then let go
Provocative Test for ACL, PCL and Meniscus

Front 25

Collateral ligaments
valgus stress tests

Back 25

In neutral (extension) or with 30 degrees of flexion
- L-M force (VALGUS) applied over knee joint
Place your hand either on the femur or the tibia when applying valgus force to be more specific

Front 26

Varus Stress test

Back 26

To test the lateral collateral ligament apply VARUS stress to the knee joint on the lateral side

Front 27

Cruciate ligaments:
anterior drawer sign

Back 27

Anterior cruciate ligament
Positive: Instability, increased mobility

Front 28

posterior drawer sign

Back 28

Posterior cruciate ligament
Positive: Instability, increased mobility

Front 29

Lachman’s test

Back 29

Anterior cruciate (Better test- Gold standard)
Patient knee flexed to 30 degree, so as to be in the open-packed position
Support the patient femur and apply a P-A force to the back of the knee

Front 30

Reverse lachman’s

Back 30

Posterior cruciate ligament
- Put the patient knee in 30 degree flexion, open packed position
- Support at the femur and on the tibia and apply a force in the A-P direction

Front 31

Pivot shift test

Back 31

IR Tibia on fully extended knee with VALGUS stress
- Clunks about 20o knee flexion
- Deficiency of ACL (grade 1 or 2 tear)

Front 32

Reverse pivot shift test

Back 32

ER on fully flexed knee with VALGUS stress
Extent- Clunk at about 40o flexion
- Deficiency of PCL (grade 1 or 2 tear)

Front 33

Slocum’s test

Back 33

Knee flexed to 90o P-A Drawer with:
- Internal rotation- ACL, Lateral capsule/Lig, ITB
- External rotation- ACL, Medial capsule/Lig

Front 34

Posterior sag

Back 34

PCL tear
Look for dropping of leg

Front 35

Menisci:
McMurray’s test- Loose fragment

Back 35

Medial Meniscus: (PIC) - Hip flexed at 90 degrees and tibia flexed at knee with external rotation,

Lateral Meniscus: - Hip flexed at 90 degrees and tibia flexed at knee with internal rotation,

- Reproduces a pain or click in joint space

Front 36

Joint line tenderness

Back 36

Front 37

Steinmann’s tenderness displacement test

Back 37

With knee in FLEXION palpate most tender point on joint line. Pain disappears if meniscus lesion as meniscus move forward when you extend the knee.

Medial pain is elicited on lateral rotation, and lateral pain is elicited on medial rotation.

Front 38

Apley’s test grind/distraction

Back 38

- Compression (grind)= increased pain
- Distraction= decreased pain
- Indication of meniscus lesion

Front 39

Thessaly test

Back 39

Produce pain on side where there is pain on damaged meniscus side

Front 40

Effusion:
Patellar tap test/ Bulge or sweep (Milking)

Back 40

- Tap on top of patella, look for radiating pain
- Fluid movement from milking/ sweeping
- Ppl with large adipose tissue build up and damage to knee region

Front 41

Patella ballottement

Back 41

Push patella into joint and release suddenly patella seen to rise visibly. Positive test if patella slowly floats

Front 42

Patella:
Apprehension test

Back 42

Pain, uncomfortable (Push M-L) The knee flexed to 30°
If the patient feels the patella is going to dislocate, the patient will contract the quadriceps muscles to bring the patella back "into line."

Front 43

Grinding test/Fouchet’s

Back 43

Twist and grind patella with compression- Positive if pain present

Front 44

Clarks

Back 44

Pain on compression and Quads contraction

Front 45

5 Perform the following functional tests for the knee and lower leg region:
a) Screw Home Mechanism + VMO assessment
(Timing, Quality and Quantity, Pain)

Back 45

Start with patient in sitting position. (Knees flexed).
- Place a pen mark on the tibial tuberosity.
- Place a pen mark on the inferior pole of the patella.
- The patient is asked to actively extend the knee.
- Observes for (Lateral movement/External rotation of the tibia) with Slight medial/internal rotation of the patella (pulled by the Vastus Medius)

Palpate- Patella, Tibial tiberosity, Vastus medialis
Factors- DJD, Tracking syndrome, knee reco or replacement, condromelasia

Throughout your observation and palapation you are assessing QQTP as a whole and comparing side to side. Look for asymmetry. The most reliable indicator is the Vastus Medius contraction
Screw Home Mechanism: Tiba rotates externally, Vastus Medialis which counteracts the lateral pull of Vastus lateralis, ITB and Rectus Femoris. VM has a controlling action

Front 46

b) Squat assessment – Heels on/off (TQQP)

Back 46

Front 47

c) One legged hop

Back 47

Front 48

d) Step up-step down

Back 48

Front 49

e) Functional genu valgus/varus assessment

Back 49

A- Valgus
B- Varus

Front 50

f) Assess the Q angle

Back 50

1. Patient standing in neutral position.
2. Mark the middle of the patella.
3. Draw a line from the mid-tibial tuberosity to the
patella.
4. Draw a line from the ASIS to the patella.
5. Measure the inside angle between the two lines below the patella intersection.

o Males will have 5-15 degrees
o Females will have a larger Q angle at 10-20 degrees

Front 51

McMurray’s Modification Technique #1Tibial knee external rotation and abduction (slow manoeuvre with traction)

Back 51

Displacement/ Minor tears of medial meniscus.
The foot and leg are externally rotated. VALGUS force, traction applied

Lateral meniscus- Contralateral, tibial internal rotation and adduction force (varus) combined with the traction.

Front 52

McMurray’s Modification Technique #2 Tibial knee external rotation and abduction (circumduction with thrust)

Back 52

Displacement/ Minor tears of medial meniscus.
The foot and leg are externally rotated. VALGUS force, Thrust applied

Lateral meniscus- Contralateral, tibial internal rotation and adduction force (varus) combined with the thrust.

Front 53

Alternating circumduction and extension

Back 53

Traction Applied (side-to-side movement at the end)
Medial meniscus- the knee in valgus position and then circumducted medially with extension
Lateral meniscus- The knee is placed is a varus position and circumducted laterally. with extension

Front 54

A-P drawer technique

Back 54

Can be applied as set thrust 6-12 times
OR
A-P movement 30-60 times

Front 55

Tibiofemoral circumduction technique

Back 55

Front 56

Tibial rotation technique

Back 56

Front 57

Apley’s modification Technique

Back 57

Front 58

Gertler’s technique

Back 58

Internal and external rotation with traction

Front 59

Popliteal (flexion) stretch (prone/supine)

Back 59

Front 60

Medial tibia subluxation adjustment technique

Back 60

Front 61

Lateral tibia subluxation adjustment technique

Back 61

Front 62

External rotation subluxation tibia adjustment [external rotary knee adjustment]

Back 62

Run up technique- thrust IR at end of motion

Front 63

Internal rotation subluxation tibia adjustment [internal rotary knee adjustment)

Back 63

Run up technique- thrust ER at end of motion

Front 64

Tibial lift technique

Back 64

Loss of P-A glide or distraction (locked knee)

Front 65

Posterior fibula subluxation technique (supine and prone)

Back 65

Front 66

Posterior tibia subluxation technique (supine and prone)

Back 66

Front 67

Superior/inferior fibula subluxation technique

Back 67

Front 68

Patella adjustment technique

Back 68