Knee Flashcards
1
Q
What are the key functions of the knee?
A
- Stabilising and supporting body weight
- Movement
- Shortening and lengthening of the lower limb
2
Q
What is the structure of the femoral head?
A
It is slightly more than half a sphere, entirely coated in hyaline cartilage except for fovea capitis which serves as the attachment point for ligamentum teres.
3
Q
What is the landmark where the femoral neck meets the femoral shaft?
A
The intertrochanteric line
4
Q
What lines can be found on the femur?
A
The gluteal tuberosity laterally and pectineal line medially come together to form linea aspera.
Linea aspera then splits distally into medial and lateral supracondylar lines which run down to the femoral condyles.
5
Q
What feature of the femur helps increase the articulating surface with the tibia and what is the result of this?
A
The projection of femoral condyles backwards beyond the posterior surface of the shaft increases the articulating surface with the tibia and improves load distribution and balance.
6
Q
Which femoral condyle is wider: medial or lateral?
A
Lateral
7
Q
What is found between the two femoral condyles?
A
The intercondylar notch, where the patella tracks.
8
Q
Which parts of the femur are palpable?
A
- Greater trochanter
- Medial femoral condyle
- Lateral femoral condyle
- Adductor tubercle
9
Q
What type of bone is the patella?
A
It is a triangular sesamoid bone
10
Q
What is a sesamoid bone?
A
This is a bone embedded in a muscle, tendon or ligament at, or near, a joint surface
11
Q
Where are the apex and base of the patella?
A
The apex is the inferior surface, the base is the superior surface.
12
Q
Why are there a series of roughened ridges anteriorly on the patella?
A
The passing of quadriceps femoris fibres over the patella creates these scuffs.
13
Q
What is the structure of the posterior articulating surface of the patella?
A
It is a large smooth oval facet, coated with hyaline cartilage for articulation with the patellar surface of the femur. A broad vertical ridge separates the facet into a small medial facet and a larger lateral facet.
There are also two horizontal lines which separate each side into upper, middle and lower sections.
14
Q
What is the roughened area at the posterior of the apex of the patella for?
A
Attachment of ligamentum patellae (patellar tendon)
15
Q
What is the roughened area at the posterior of the base of the patella for?
A
This is for attachment of rectus femoris and vastus intermedius centrally, vastus medialis medially and vastus lateralis laterally.
16
Q
Which parts of the patella can be palpated?
A
All the anterior surface
17
Q
Which is the longer of the two bones in the lower leg?
A
Tibia
18
Q
What is the structure of the proximal tibia?
A
It has two condyles which project posteriorly beyond the shaft, helping distribute weight. There is a large tibial tuberosity between them anteriorly and a smooth surface posteriorly.
Superiorly there are two ovular articulating facts coated with hyaline cartilage. They are separated by two raised intercondylar eminences (medial and lateral).
19
Q
Why does the lateral condyle of the tibia project further laterally than the shaft?
A
This provides space for a round articular facet to articulate with the head of the fibula.
20
Q
What is the structure of the tibial shaft?
A
It is triangular in cross section and tapers from the condyles for about two-thirds of its length and then widens again distally.
21
Q
Where does the anterior border run on the tibial shaft?
A
From the tibial tuberosity to the anterior part of the medial malleolus.
22
Q
Where does the medial border of the tibial shaft run?
A
From below the posterior aspect of the medial condyle inferiorly to the posterior part of the medial malleolus.
23
Q
Where does the interosseous border of the tibial shaft run?
A
From below the articular facet on the lateral tibial condyle in a curved line to the lateral side of the distal end of the bone.
24
Q
What are the 3 surfaces of the tibial shaft?
A
Medial surface (shin) - Between medial and anterior borders
Lateral surface - Between anterior and interosseous borders
Posterior surface - Between medial and interosseous borders
25
What crosses the posterior surface of the tibial shaft?
The soleal line from the lateral condyle inferomedially to the medial border half way down.
26
What is the structure of the distal tibia?
It has a prominent medial malleolus, continuous with the medial end of the shaft. It has an inferior surface which articulates with the body of talus. It has a lateral surface which becomes concave for articulation with the fibula.
27
Which parts of the tibia are palpable?
* Tibial tuberosity
* Medial and lateral tibial condyles
* Medial surface (shin)
* Medial malleolus
28
What is the structure of the proximal fibula?
It has a widened proximal end (head) which has a superomedial facet to articulate with the lateral condyle of the tibia. There is then a small neck below around which runs the common fibular nerve.
29
What are the 3 borders of the fibular shaft?
Anterior border - Becomes prominent inferiorly where is become continuous with the lateral malleolus
Interosseous border - Sits medially to the anterior border but is often poorly visible
Posterior border - Runs from lateral aspect of fibular head to the medial margin of the posterior surface of the lateral malleolus.
30
What are the 3 surfaces of the fibular shaft?
Anterior surface - Between anterior and interosseous borders
Lateral surface - Concave surface posterolateral to the anterior border
Posterior surface - The largest of the surfaces of the fibula
31
What is the structure of the distal fibula?
It is flattened medially and laterally with a deep malleolar fossa posteriorly. Above this fossa on the medial side there is a triangular area for articulation with the lateral surface of the body of talus.
32
What parts of the fibula are palpable?
* Head of fibula
* Lateral malleolus
33
What type of joint is the tibiofemoral joint?
Synovial hinge joint
34
What is the structure of the articulating surfaces of the tibiofemoral joint?
The medial and lateral femoral condyles are convex and articulate with the slightly concave tibial plateau (tibial condyles). There is a thick layer of hyaline cartilage across the articulating surfaces.
35
What is the role of the menisci?
The tibial plateau is not sufficiently concave to be congruent with the femoral condyles so the medial and lateral menisci increase the concavity and help to evenly distribute femoral pressure across the tibia.
36
What are menisci?
They are crescent-shaped fibrocartilaginous structures which help distribute femoral pressure on the tibia and improve congruence at the tibiofemoral joint.
37
What in the tibiofemoral joint permits a small amount of axial rotation?
The intercondylar eminences on the tibia serve as a pivot which allow a small amount of axial rotation in the femur.
38
What are the attachments of the knee joint capsule?
The margins of the femoral and tibial articulating surfaces. There is an opening at the front for the patella and the capsul attaches to the patellar borders. There is an opening at the back for the popliteal tendon to pass through.
39
What is the structure of the knee joint capsule?
It has an outer fibrous layer and an inner synovial membrane which lubricates articulating surfaces of the joint.
40
Which muscle blends with the anterolateral aspect of the knee joint capsule?
Tensor fascia lata
41
Which bursae are found around the knee joint?
* Suprapatellar bursa (above the patella)
* Prepatellar bursa (in front of the patella)
* Deep infrapatellar bursa (behind the patellar tendon)
* Subcutaneous infrapatellar bursa (above the patellar tendon)
* Lateral subtendinous bursa of gastrocnemius (posterolaterally)
42
Which tendon is the patella embedded in?
The quadriceps tendon
43
What is the articulation of the patellofemoral joint?
Concave medial and lateral facets on the posterior surface of the patella articulate with the intercondylar groove of the femur. Both surfaces are coated with thick hyaline cartilage.
There is also an inferomedial facet, called the odd facet, lacking cartilage which interacts with the femur during knee flexion.
44
What are the extracapsular ligament of the knee?
* Patellar ligament/tendon
* Medial collateral ligament
* Lateral collateral ligament
* Oblique popliteal ligament
* Arcuate popliteal ligament
45
Where does the patellar ligament/tendon attach?
To the tibial tuberosity.
46
What is the function of the patellar tendon?
It stabilises the tendon and prevents its displacement.
47
What are the attachments of the lateral collateral ligament of the knee?
The LCL attaches to the lateral epicondyle of the knee behind the attachment of popliteus and extends distally to the lateral surface of the fibular head.
48
Which of the collateral ligaments of the knee blends with the joint capsule?
Medial collateral ligament
49
What are the attachments of the medial collateral ligament of the knee?
The MCL attachs to the medial femoral condyle and attaches to the medial tibial condyle and medial side of the tibial shaft.
50
What is the function of the medial collateral ligament of the knee?
It prevents excessive sideways movement and rotation of the knee joint.
51
What does the oblique popliteal ligament originate from?
An expansion of the semimembranosus tendon.
52
What are the attachments of the oblique popliteal ligament?
It attaches posteriorly to the medial tibial condyle and moves superolaterally and attaches to the lateral femoral condyle.
53
How does the oblique popliteal ligament contribute to the knee joint capsule?
It reinforces the posterior aspect of the joint capsule.
54
What are the attachments of the arcuate popliteal ligament?
It is a thick fibrous band from the posterior aspect of the fibular head which goes superomedially and attaches to the centre of the oblique popliteal ligament.
55
What role does the arcuate popliteal ligament play in the knee joint capsule?
It reinforces the posterolateral part of the joint capsule.
56
Which movement is limited by the arcuate popliteal ligament?
Knee overextension
57
What are the intracapsular ligament of the knee?
Anterior cruciate ligament
Posterior cruciate ligament
58
What are the attachments of the ACL?
It originates from the anterior intercondylar area of the tibia just behind the medial meniscus attachment and extends superoposterolaterally and attaches to the medial surface of the lateral femoral condyle.
59
How much spiral is there in the ACL?
110 degrees
60
What is the transverse ligament?
This is a small ligament which connects the two menisci
61
What does the ACL blend with?
It passes beneath the transverse ligament and blends with the anterior horn of the lateral meniscus
62
What is the function of the ACL?
It prevents posterior rolling and displacement of the femoral condyle during flexion and prevents knee hyperextension.
63
What are the attachments of the posterior cruciate ligament?
It originates from the posterior intercondylar area of the tibia and extends superoanteromedially and attaches to the lateral surface of the medial femoral condyle.
64
Which is stronger ACL or PCL?
PCL and it also has better blood supply
65
What is the function of the PCL?
It prevents anterior rolling and displacement of the femoral condyle during extension and prevents hyperflexion of the knee. It is also the main stabiliser of knee joint rotation.
66
What is the structure of menisci?
They are crescent shaped and have an outer third (red zone) which is vascularised and inner two-thirds (white zone) which is avascular and thin.
67
How are meniscal collagen fibres oriented?
The deep collagen fibres are circumferentially oriented which promotes dispersion of circumferential forces.
The superficial meniscal fibres are radially oriented to resist longitudinal stresses.
The most superficial fibres are randomly oriented to help distribute shear stress.
68
Which ligaments hold the menisci in place?
* Transverse ligament
* Meniscofemoral ligament
* Meniscotibial ligament
69
What is the most common meniscal injury?
Bucket handle injuries where the weaker internal fibres separate from the stronger peripheral fibres and rise up and hook around the femoral condyle, causing reduced ROM and a clicking/locking feeling.
70
What shape is the medial meniscus?
It is C-shaped
71
What are the attachments of the medial meniscus?
Its anterior horn attaches to the anterior intercondylar area of the tibia and blends with the ACL.
Its posterior horn attaches to the posterior intercondylar area of the tibia between the attachments of the lateral meniscus and of the PCL.
72
What shape is the lateral meniscus?
Almost circular
73
What are the attachments of the lateral meniscus?
Its anterior horn attaches to the anterior intercondylar area of the tibia and partially blends with the ACL.
Its posterior horn attaches to the posterior intercondylar area of the femur anterior to the posterior horn of the medial meniscus.
74
Which bursa separates the MCL from the anserine tendons?
Pes anserine bursa
75
What are the origins of semimembranosus?
Lateral aspect of the ischial tuberosity
76
What are the insertions of semimembranosus?
Medial tibial condyle
77
Which actions are mediated by semimembranosus?
* Hip extension
* Knee flexion
* Knee medial rotation
78
Which nerves innervate semimembranosus?
Tibial branch of the sciatic nerve
79
Which blood vessels supply semimembranosus?
Deep femoral artery
80
Which structures are posterior to semimembranosus?
Semitendinosus
81
Which structures are anterior to semimembranosus?
Adductor magnus
82
Which structures are lateral to semimembranosus?
* Long head of biceps femoris
* Sciatic nerve
* Semimembranosus bursa
83
Which structures are medial to semimembranosus?
Gracilis
84
How can you strengthen semimembranosus?
* Nordic hamstring curls
* Leg curls
* Leg press
* Romanian deadlift
85
How do you stretch semimembranosus?
* Place the bottom of your heel on a chair and lean forward towards that leg
* Stand behind a chair and lean forward, keeping legs straight
* Resistance band stretch of gastrocnemius and hamstrings
86
How do you palpate semimembranosus?
1. Find the semitendinosus tendon on the medial aspect of the knee and follow it up
2. Palpate deeply either side of the tendon to find semimembranosus
3. Perform resisted knee flexion to feel semimembranosus
87
Why is semimembranosus called as such?
Because it has a long, flat, membranous structure
88
What does the distal tendon of semimembranosus give rise to?
The oblique popliteal ligament
89
What type of muscle in semimembranosus?
Unipennate
90
What are the origins of semitendinosus?
Ischial tuberosity
91
What are the insertions of semitendinosus?
Pes anserine on the medial aspect of the proximal tibia
92
Which actions are mediated by semitendinosus?
* Hip extension
* Knee flexion
* Knee medial rotation
93
Which nerves innervate semitendinosus?
Tibial branch of sciatic nerve
94
Which blood vessels supply semitendinosus?
* Deep femoral artery
* Medial circumflex femoral artery
95
Which structures are anterior to semitendionsus?
Semimembranosus
96
Which structures are lateral to semitendinosus?
* Long head of biceps femoris
* Tibial collateral ligament
* Anserine bursa
97
How do you palpate semitendinosus?
1. Palpate the ischial tuberosity
2. Perform prone resisted flexion and itendify the clear tendon above the medial side of the popliteal fossa
3. Follow this tendon up to the popliteal fossa
98
How can you strengthen semitendinosus?
* Nordic hamstring curls
* Leg press
* Leg curls
* Romanian deadlift
99
How can you stretch semitendinosus?
* Place the bottom of your heel on a chair and lean forward towards that leg
* Stand behind a chair and lean forward, keeping legs straight
* Resistance band stretch of gastrocnemius and hamstrings
100
What type of muscle is semitendinosus?
Fusiform
101
Which muscles make up pes anserinus?
* Semitendinosus
* Gracilis
* Sartorius
102
What are the origins of biceps femoris?
* Ischial tuberosity
* Linea aspera (short head)
* Lateral supracondylar line (short head)
103
What are the insertions of biceps femoris?
Head of fibula
104
Which actions are mediated by biceps femoris?
* Hip extension
* Knee flexion
* Knee lateral rotation
105
Which nerves innervate biceps femoris?
Tibial branch of sciatic nerve (long head)
Common fibular branch of sciatic nerve (short head)
106
Which blood vessels supply biceps femoris?
* Deep femoral artery
* Inferior gluteal artery (long head only)
* Medical circumflex femoral artery (long head only)
107
Which structures are posterior to biceps femoris?
Gluteus maximus
108
Which structures are anterior to biceps femoris?
* Femur
* Adductor magnus
* Vastus lateralis
* Sciatic nerve
109
Which structures are lateral to biceps femoris?
Tensor fascia lata and iliotibial tract
110
Which structures are medial to biceps femoris?
* Semimembranosus
* Semitendinosus
111
How can you strengthen biceps femoris?
* Leg curls
* Squats
* Hip thrusts
112
How do you stretch biceps femoris?
* Put the soles of one foot against the knee of the other and lean towards the outstretched leg.
* Resistance band stretch of gastrocnemius and hamstrings.
113
How do you palpate biceps femoris?
1. In prone, ask the patient to perform resisted knee flexion
2. Palpate the head of the fibula and palpate up to the ischial tuberosity for the long head
3. For the short head, palpate up the long head tendon and palpate deeply to the long head to find the short head insertion
114
What type of muscle is biceps femoris?
Fusiform
115
What are the origins of sartorius?
ASIS
116
What are the insertions of sartorius?
Pes anserinus on the medial aspect of the proximal tibia
117
What functions are mediated by sartorius?
* Knee flexion
* Knee medial rotation
* Assists in hip flexion, hip abduction and hip lateral rotation
118
Which nerves innervate sartorius?
Femoral nerve
119
Which blood vessels supply sartorius?
Femoral artery
120
Which structures are posterior to sartorius?
* Rectus femoris
* Adductor longus
* Vastus medialis
* Gracilis
121
Which structures are lateral to sartorius?
Tensor fascia lata
122
Which structures are medial to sartorius?
Iliopsoas
123
How can you strengthen sartorius?
* Lateral step ups
* Resistance band crab walks
* Clamshells
124
How can you stretch sartorius?
* Lunge and push your hips forward while contracting gluteus maximus
* In prone, grab one ankle and pull it towards your buttocks
125
How do you palpate sartorius?
1. Palpate the inferior aspect of ASIS and you will feel the tendinous attachment of sartorius.
2. Ask the patient to perform hip flexion, abduction and external rotation while flexing their knee. If you resist these movements you will see the muscle band of sartorius start to show up and it can be followed inferoposteromedially to the pes anserinus.
126
What type of muscle is sartorius?
A strap-like muscle
127
What structures does sartorius contribute towards?
* Adductor canal
* Femoral triangle
128
What are the origins of gracilis?
* Inferior pubic ramus
* Body of pubis
129
What are the insertions of gracilis?
Pes anserinus on the medial aspect of the proximal tibia
130
Which actions are mediated by gracilis?
* Hip adduction
* Knee flexion
* Knee medial rotation
131
Which nerves innervate gracilis?
Obturator nerve
132
Which blood vessels supply gracilis?
* Deep femoral artery
* Deep circumflex femoral artery
133
Which structures are posterior to gracilis?
Semitendinosus
134
Which structures are anterior to gracilis?
Sartorius
135
Which structures are lateral to gracilis?
* Adductor magnus
* Adductor longus
* Semimembranosus
* Tibial collateral ligament (MCL)
* Anserine bursa
136
How do you strengthen gracilis?
* Banded hip adduction
* Adductor machines
* Resisted butterfly stretch
137
How do you stretch gracilis?
* Supine bent knee fallout with soles of feet together
* Wide side lunges
138
How do you palpate gracilis?
1. With the patient in supine place their knee and hip into flexion and place your knee underneath for support
2. Ask the patient to dig their heel into the bed and perform resisted adduction
3. Gracilis will be the posterior of two bands that appear (the other being adductor longus)
4. Palpate towards pes anserinus for the insertion (but sartorius overlaps near the insertion)
5. Palpate towards the origins if the patient creates a genital border with their hand
139
What type of muscle is gracilis?
A long fusiform muscle
140
How is gracilis often used in surgery?
In wide margin tumour resections in the arm, gracilis is often used as a muscle graft as it is not essential to any function and has been shown to maintain contractile properties well after grafting.
141
What are the origins of popliteus?
Groove on the lateral face of the lateral femoral condyle
142
What are the insertions of popliteus?
Posterior surface of the tibia, superior to the soleal line
143
Which actions are mediated by popliteus?
* Medial rotation of the knee
* Unlocking of the knee at the start of flexion
144
Which nerves innervate popliteus?
Tibial branch of the sciatic nerve
145
Which blood vessels supply popliteus?
* Inferior medial genicular artery
* Inferior lateral genicular artery
146
Which structures are deep to popliteus?
* Lateral femoral condyle
* Posterior proximal tibia
147
Which structures are superficial to popliteus?
* LCL
* Plantaris
* Medial and lateral heads of gastrocnemius
* Biceps femoris tendon
* Popliteal vessels
* Tibial nerve
148
How do you strengthen popliteus?
Step up and step downs either side of a step, keeping one leg on the step throughout
149
How do you stretch popliteus?
Stand facing a wall with your hands on it. Bend your front knee and step back with your oter leg and press your heel into the ground.
150
How do you palpate popliteus?
It is not feasible to palpate popliteus as it is deep to both heads of gastrocnemius
151
What type of muscle is popliteus?
Triangular
152
What forms the floor of the popliteal fossa?
Popliteus
153
How does popliteus unlock the knee?
In full extension the femur is locked by medial rotation. Popliteal contraction with a fixed tibia results in lateral rotation of the femur, unlocking the knee.
154
What are the origins of gastrocnemius?
* Lateral femoral condyle (lateral heaed)
* Lateral supracondylar line (lateral head)
* Medial femoral condyle (medial head)
* Popliteal surface of the femur (medial head)
155
What are the insertions of gastrocnemius?
Posterior surface of the calcaneus via the Achilles/calcaneal tendon
156
Which actions are mediated by gastrocnemius?
* Knee flexion
* Ankle plantarflexion
157
Which nerves innervate gastrocnemius?
Tibial branch of the sciatic nerve
158
Which blood vessels supply gastrocnemius?
Sural arteries
159
Which structures are superficial to gastrocnemius?
* Biceps femoris tendon (superficial to lateral head)
* Semimembranosus tendon (superficial to medial head)
160
Which structures are deep to gastrocnemius?
* Soleus
* Popliteus
* Plantaris (medial head)
* Oblique popliteal ligament
* Medial and lateral subtendinous bursae of gastrocnemius
* Tibial vessels
* Tibial nerve
161
Which structures are lateral to gastrocnemius?
Common fibular nerve
162
Which structures are medial to gastrocnemius?
Great saphenous nerve and vein
163
How do you strengthen gastrocnemius?
Calf raises
164
How do you stretch gastrocnemius?
* Resistance band stretch
* Stand on a step with heels hanging off the edge and drop downwards
* Stand with one foot close to the other and step back with the other foot so front leg is bent and back leg is straight
165
How do you palpate gastrocnemius?
1. With the patient in prone, flex their knee and place your knee beneath their shin
2. Palpate the medial and lateral femoral condyles posteriorly and perform resisted plantarflexion and you will see the muscle contract and you can follow this down to the Achilles tendon.
166
What sort of muscle is gastrocnemius?
Fusiform
167
What structures to the heads of gastrocnemius contribute to?
The lateral head forms the inferolateral boundary of the popliteal fossa and the medial head forms the inferomedial boundary.
168
What are the origins of rectus femoris?
* AIIS
* Supraacetabular groove of the ilium
169
What are the insertions of rectus femoris?
Tibial tubercle via the quadriceps tendon
170
Which actions are mediated by rectus femoris?
* Hip flexion
* Knee extension
171
Which nerves innervate rectus femoris?
Femoral nerve
172
Which blood vessels supply rectus femoris?
* Deep femoral artery
* Lateral circumflex femoral artery
173
Which structures are posterior to rectus femoris?
* Vastus intermedius
* Iliofemoral ligament
174
Which structures are anterior to rectus femoris?
Sartorius
175
Which structures are lateral to rectus femoris?
Tensor fascia lata and the iliotibial tract
176
Which structures are medial to rectus femoris?
Vastus medialis
177
How do you strengthen rectus femoris?
* Straight leg raises
* Squats
* Resisted knee extension
178
How do you stretch rectus femoris?
* Pull ankle towards your bum
* Kneeling lunge whilst pushing your hip forward and bringing your back ankle towards your bum
179
How do you palpate rectus femoris?
1. Palpate ASIS and move inferiorly to AIIS
2. Ask the patient to lock their knee and lift their leg off the table and you will see the muscle belly and can palpate down as far as the quadriceps tendon.
180
What type of muscle is rectus femoris?
Bipennate
181
What are the origins of vastus intermedius?
Anterior and lateral surfaces of the body of the femur
182
What are the insertions of vastus intermedius?
Tibial tuberosity via the quadriceps femoris tendon
183
Which actions are mediated by vastus intermedius?
Knee extension
184
Which nerves supply vastus intermedius?
Femoral nerve
185
Which blood vessels supply vastus intermedius?
Deep femoral artery
186
Which structures are posterior to vastus intermedius?
* Femur
* Articularis genus
187
Which structures are anterior to vastus intermedius?
Rectus femoris
188
Which structures are lateral to vastus intermedius?
Vastus lateralis
189
Which structures are medial to vastus intermedius?
Vastus medialis
190
How do you strengthen vastus intermedius?
* Squats
* Step ups
191
How do you stretch vastus intermedius?
Pull your heel towards your bum
192
How do you palpate vastus intermedius?
1. Palpate rectus femoris
2. Move laterally and dig your fingers beneath and ask the patient to extend their knee with their hip in a neutral position and vastus intermedius will push your fingers out
193
What type of muscle is vastus intermedius?
Bipennate
194
What are the origins of vastus lateralis?
Anterior and lateral surface of the proximal femur
195
What are the insertions of vastus lateralis?
Tibial tuberosity via the quadriceps femoris tendon
196
Which actions are mediated by vastus lateralis?
Knee extension
197
Which nerves innervate vastus lateralis?
Femoral nerve
198
Which blood vessels supply vastus lateralis?
* Deep femoral artery
* Lateral circumflex femoral artery
199
Which structures are posterior to vastus lateralis?
Biceps femoris (long and short heads)
200
Which structures are lateral to vastus lateralis
* Tensor fascia lata
* Iliotibial tract
201
Which structures are medial to vastus lateralis?
* Rectus femoris
* Vastus intermedius
* Articularis genus
202
How do you strengthen vastus lateralis?
* Squats
* Leg extensions with toe pointed in
* Leg press
203
How do you stretch vastus lateralis?
* Lunges where you push your hips forward and pull your back ankle towards your bum
* Pull your ankle towards your bum
204
How do you palpate vastus lateralis?
1. With the patient in supine, ask them to extend their knee
2. Palpate from the patellar tendon along the lateral face of the thigh
3. If you ask the patient to raise their leg off the table you can find the lateral border of rectus femoris which marks the medial border of vastus lateralis
4. If you ask the patient to bend their knee and dig their heels into the bed then you will feel the border with biceps femoris posteriorly
5. Betwne these two borders is vastus lateralis
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Which is the largest of the quadriceps muscles?
Vastus lateralis
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What type of muscle is vastus lateralis?
Bipennate
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What are the origins of vastus medialis?
* Medial part of the intertrochanteric line
* Medial lip of linea aspera
* Medial supracondylar line
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What are the insertions of vastus medialis?
* Medial border of the patella
* Tibial tuberosity via the quadriceps tendon
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Which actions are mediated by vastus medialis?
Knee extension
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Which nerves innervate vastus medialis?
Femoral nerve
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Which blood vessels supply vastus medialis?
Femoral artery
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Which structures are posterior to vastus medialis?
* Adductor longus
* Adductor magnus
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Which structures are anterior to vastus medialis?
Sartorius
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Which structures are lateral to vastus medialis?
* Rectus femoris
* Vastus intermedius
* Articularis genus
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How do you strengthen vastus medialis?
* Squats
* Leg raises with feet pointed outwards (varus)
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How do you stretch vastus medialis?
* Pull your heel towards your bum
* Lunge where you push hips forwards and pull back heel towards your bum
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How do you palpate vastus medialis?
1. Palpate the medial border of the patella and ask the patient to lock their knee
2. Follow the muscle up the thigh below rectus femoris
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What type of muscle is vastus medialis?
Bipennate
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Which structure does vastus medialis contribute to?
Adductor canal
220
What percentage of femoral fractures are femoral condyle fractures?
3-6%
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What is the most common mechanism of femoral condyle fractures?
* Jumping from a height
* Car accidents
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What are causes of low energy femoral condyle fractures in older people with osteoporosis?
* Rapid twisting motions or falls
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How does muscle activity often worsen femoral condyle fractures?
Hamstring, extensor and adductor magnus activity often displace the fracture.
224
What are the clinical features of femoral condyle fractures?
* High level of pain, especially on weight bearing
* Swelling and bruising
* Tenderness to touch
* Deformity
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What classification is used for distal femur fractures?
Orthopaedic trauma association classification
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What are class A distal femur fractures according to Orthopaedic Trauma Association Classification?
These are extra-articular fractures
A1 - Simple extra-articular
A2 - Metaphyseal wedge
A3 - Metaphyseal complex
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What are type B distal femur fractures according to Orthopaedic Trauma Association Classification?
Class B distal femur fractures are partial articular fractures.
B1 - Lateral condyle
B2 - Medial condyle
B3 - Coronal plane
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What are type C distal femur fractures according to the Orthopaedic Trauma Association Classification?
Class C distal femur fractures are complete articular fractures.
C1 - Simple articular, simple metaphyseal
C2 - Simple articular with metaphysal communition
C3 - Metaphyseal and intra-articular comminution
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How are distal femur fractures managed surgically?
Screw fixation if extra-articular or simple intra-articular.
ORIF if more complex.
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Other than surgery, how else are distal femur fractures managed?
* Gentle ROM exercise post-operatively
* Post-operative mobilisation on two elbow crutches for 14 days post-surgery
* Post-operative muscle strengthening (in particular quadriceps, hamstrings and gluteals)
* Stair climbing after 7-14 days
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What are the most common causes of patellar fractures?
* Direct violence to the patella
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What are the clinical features of patella fractures?
* Inability to extend the knee
* Bruising and abrasion
* Tenderness
* Palpable gaps above or below the patella
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What are the difference classifications of patellar fractures?
* Vertical
* Undisplaced
* Displaced
*
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How are vertical patella fractures usually managed?
With casts as they are usually not displaced
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How are horizontal patellar fractures managed?
Undisplaced horizontal fractures can be managed with casts whilst displaced fractures require internal dixation or partial patellectomy.
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What are the most common causes of tibial plateau fracture?
* High energy impacts usually involving valgus/varus loading
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What are the clinical features of tibial plateau fractures?
* Knee pain
* Oedema
* Damage to surrounding vasculature, nerves, ligaments or menisci
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What classification system is used to classify tibial plateau fractures?
Schatzker classificaiton system
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What are the gradese of Schatzker tibial plateau fracture?
1. Lateral plaeatu split fracture
2. Lateral plateau split depressed fracture
3. Lateral plateau pure depression fracture
4. Medial plateau fracture
5. Bicondylar plateau fracture
6. Metaphyseal-diaphyseal dissociation fracture
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Why are medial tibial plateau fractures graded more highly than lateral fractures in the Schatzker classification?
Because the medial plateau is thick and stronger
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How are tibial plateau fractures managed?
For minimally displaced fractures without ligamentous injury, a hinged knee brace is used for 6-8 weeks with passive ROM exercise. Partial weight bearing is then used for a further 6 weeks then full weight bearing as tolerated.
This is done alongside strength training.
For more displaced fractured, or those with ligamentous damage, ORIF is used.
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How are highly comminuted tibial plateau fractures managed?
External fixation
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What are the most common causes of tibial spiral fractures?
Low energy torsional forces e.g., turning your hip with your foot fixed
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What are the most common causes of tibial wedge or short oblique fractures?
Direct high energy trauma
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What are the clinical features of tibial fractures?
* Pain
* Inability to weight bear
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What is the classification system for closed tibial fractures?
Oestern and Tscherne classification system
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What are the grades of closed tibial fracture in the Oestern and Tscherne classification?
* Grade 0 - Injuries from indirect forces with minimal soft tissue damage
* Grade 1 - Superficial contusion/abrasion with a simple fracture
* Grade 2 - Deep abrasions, contusions and a fracture leading to risk of compartment syndrome
* Grade 3 - Extension contusion, crushed skin, muscle destruction, subcutaneous degloving, compartment syndrome and rupture of a major blood vessel or nerve
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Which classification system is used for open tibial fractures?
Gustilo-Anderson classification system
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What are the types of tibial open fractures according to the Gustilo-Anderson system?
* Type 1 - Limited periosteal stripping. Clean wound <1cm
* Type 2 - Mild-to-moderate periosteal stripping. Wound >1cm
* Type 3A - Significant soft tissue injury and periosteal stripping, no flap required
* Type 3B - Significant soft tissue injury and periosteal stripping, flap required
* Type 3C - Significant soft tissue injury with vascular injury requiring repair
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How are tibial fractures managed?
* Casts
* External fixation
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Why are tibial fractures often co-occurring with fibular fractures?
The interosseous membrane between them limits mobility of the two bones and results in force transmission between them.
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What is the most common cause of isolated fibula fractures?
Direct blow or blunt trauma to the fibula, although these fractures are very rare.
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What are the clinical signs of fibula fractures?
* Bruising
* Tenderness to palpation
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How are isolated fibula fractures managed?
With a rockbottom/moon boot for comfort but the fibula is not weight bearing so the fracture is not a major issue.
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At what angle of flexion does the patella begin to engage with the intercondylar groove/trochlea?
30 degrees
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At what degree of flexion does the odd facet engage with the femur?
120 degrees
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What is the purpose of the odd facet articulating with the femur?
It helps to distribute load across a largr joint area, promoting force dissemination.
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How is Q angle measured?
Angle from the ASIS to the middle of the patella compared to the angle from the middle of the patella to the tibial tuberosity.
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What is patella maltracking often caused by in young people?
Non-contact twisting with the knee extended and foot externally rotated. The patella usually self-reduces but sometimes it will not return to the correct position.
260
What are endogenous causes of patellar maltracking?
* Reduced trochlear depth
* Facet asymmetry
* High patellae
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In what percentage of patellar maltracking cases is there geometric abnormality in the shape of the trochlear groove?
85%
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In lateral patellar dislocation, which ligament is commonly damaged?
Medial patellofemoral ligament
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How is patellar maltracking managed?
* NSAIDs
* Progressive physiotherapy intervention involving closed chain exercises, ROM exercise and vastus medialis strengthening
* Surgery to repair stabilising soft tissue in extreme cases
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Which activities tend to worsen patellofemoral pain syndrome?
* Squatting
* Sitting
* Stair climbing
* Running
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What is patellofemoral pain syndrome commonly caused by?
Overuse and overload of the patellar tendon combined with:
* Biomechanical or anatomical abnormalities
* Muscular weakness
* Muscular imbalance
* Muscular dysfunction
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Weakness in which muscle causes lateral shift of the patella?
Vastus medialis
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Weakness in which muscle causes medial shift of the patella?
Vastus lateralis
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Which biomechanical/anatomical abnormalities can contribute towards patellofemoral pain syndrome?
* Weak vastus medialis or lateralis
* Knee hyperextension
* Valgus/varus knees
* IT band tightness
* Hamstring tightness
* Gastrocnemius tightness
* Excessive foot pronation
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How does tight IT band increase risk of patellofemoral pain syndrome?
Tight IT band draws the knee into a varus position, pulling the patella laterally and causing early contact between the trochlear and the odd facet of the patella, leading to irritation.
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How do tight hamstrings contribute to patellofemoral pain syndrome?
They result in greater posterior force transmission (joint reaction force) through the knee and increased pressure between the patella and femur through being more flexed.
Also with very tight hamstrings the trochlear and patella can never disengage causing inflammation.
271
How can tightness in gastrocnemius contribute to patellofemoral pain syndrome?
Tightness in gastrocnemius, as in the hamstrings, prevents full knee extension so the patella remains in contact with the trochlear and the patellofemoral joint reaction force is greater.
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What are the clinical features of patellofemoral pain syndrome?
* Pain in the knee, exacerbated by squatting or loading of the patellofemoral joint
* Cinema sign - Pain after being sat for prolonged periods
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What are proposed pathophysiology mechanisms of patellofemoral pain syndrome?
* Deformation of subchondral bone due to repetitive microtrauma leading to inflammation
* Overload of soft tissue structures
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How is patellofemoral pain syndrome managed?
* Quadriceps strengthening (to normalise patella tracking)
* IT band stretching
* Hamstring stretching
* Strengthening of the hip external rotators
275
How much do ACL and PCL rupture affect anterior draw?
ACL rupture minimally affects anterior draw whilst PCL rupture can lead to up to 25mm anterior draw.
276
What is the role of the medial collateral ligament of the knee?
* Main stabiliser of the medial knee, preventing valgus stress, rotation and anterior tibial translation
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What is the structure of the medial collateral ligament of the knee?
It has superficial components which stabilise against valgus stress. It has deep components which prevent anterior tibial translation, alongside ACL. It also branches off to form meniscofemoral and meniscotibial branches.
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From which ligament to meniscofemoral and meniscotibial ligaments originate?
Medial collateral ligament of the knee
279
What is the most common cause of MCL rupture?
Acute trauma causing excessive valgus stress, often in sports
280
What are the clinical features of MCL rupture?
* Patient describing the knee "giving out" at the moment of injury
* Rapid bruising and swelling
* Acute pain
281
How are MCL injuries diagnosed?
* Flex the knee to 30 degrees
* Apply valgus force to the knee
* Palpate to see if the medial aspect of the knee joint opens up, if it does, the MCL is injured
282
Which classification is used for MCL injuries?
Hughston's classification system
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What are the grades of MCL injury in Hughston's classification?
1. Few fibres ton, localised tenderness, no instability
2. More fibres disrupted but mainly superficial, generalised tenderness, no instability
3. Complete tear, superficial and deep, instability of the knee
284
How are grade 1 and 2 MCL injuries managed?
* Early ROM exercises followed by strength training
* Hinged knee braces to prevent further valgus injury
* Gentle transverse friction massages and Grade 1 manual therapy are also recommended by some
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How are grade 3 MCL injuries managed?
* Conservative management with exercise and hinged bracing if no other ligament are damaged
* Surgical reconstruction if other ligaments are damaged
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In what percentage of grade 3 MCL injuries are other ligaments damaged?
78%
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What is the role of the lateral collateral ligament of the knee?
* Stabilise of the knee preventing varus translation and posterolateral rotation
288
What are the most common causes of LCL injuries?
High energy blows to the anteromedial knee causing a combination of hyperextension with extreme varus force.
289
When the LCL ruptures, which other ligaments also tend to rupture?
ACL and PCL
290
What are the clinical features of LCL injury?
* History of acute injury to the medial knee while in full extension
* Reduced ROM
* Instability during weight bearing
291
What classification system is used for LCL injuries?
The Hughston classification system, as with the MCL
292
How are LCL injuries tested for?
Place the knee into 30 degrees flexion and apply varus force to the knee joint. If the lateral aspect of the joint opens up then there is LCL damage.
293
What are the most common causes of meniscal injury?
Rotational or shearing forces across the tibiofemoral joint combined with axial load e.g., picking up heavy weights, squatting, rapidly accelerating/decelerating or jumping.
294
What types of meniscal tear can occur?
* Horizontal tears, parallel with the tibial plateau
* Longitudinal tears, perpendicular to the tibial plateau
* Radial tears, diagonally through the meniscus
* Displaced tears involving a flapping piece of meniscus e.g., bucket handle injuries
295
What type of meniscal tear is most common in older people with existing degenerative changes?
Horizontal tears
296
How are meniscal tears diagnosed?
* Patient reported pop during injury which swelled over 24 hours
* Pain over the anterior joint line
* Tenderness in the joint line while sitting with knees flexed to 90 degrees
297
How are meniscal tears managed?
* Initially RICE
* NSAIDs
* Bracing
* Pain-free knee and ankle ROM exercises followed by 4-6 weeks of progressive physiotherapy
* Arthroscopic surgery (although outcomes are poor)
298
How are AP tibiofemoral joint mobilisations performed?
* Take a strangle grip over the tibial tuberosity and apply posterior pressure to the tibia.
299
How are PA tibiofemoral mobilisations performed?
Take a strangle grip on the posterior knee, just below the joint line and pull the tibia anteriorly
300
Which direction of patellofemoral manipulation are most commonly used?
Medially and caudad as lateral and cephalad tracking at the most common maltracking directions of the patella
301
What grip should be used for patella mobilisation?
V-shaped grip for medial and lateral. Finger and thumb grip for caudad and cephalad.
302
What does immediate swelling after injury in the knee indicate?
Damage to vessels
303
What does swelling over several hours post-injury to the knee indicate?
Inflammatory exudate
304
What does patient reporting of "giving way" usually mean in knee assessments?
It means that the prime suspect is ligamentous instability or insufficient muscle to support the joint
305
What is the difference between locking and pseudolocking of the knee?
Locking is caused by intra-articular issues e.g., meniscal tear whilst pseudo-locking is an unwillingness to move due to pain.
306
How does suprapatellar bursitis present?
With swelling above the knee
307
How does prepatellar bursitis present?
With swelling over the patella
308
How does anserine bursitis present?
With swelling below the knee medially.
309
What are you looking out for in a knee assessment specifically compared to other body regions?
* Varum/valgus bowing of the legs
* Muscle atrophy around the knee including quadriceps, hamstrings and calves
* Hypo/hyperextension of the knees
* Arches of the feet
* Position of the patella
310
How can you assess hamstring length?
Place the patient in 90 degrees hip flexion with knee flexed and see how far they can extend their leg. Do this with the other hand stabilising the contralateral side.
311
Which test can be used for hip flexor shortening or contracture?
Thomas test
312
Which test is used to assess IT band tightness?
Obers test
313
How is Obers test performed?
1. Place the patient in side lying and lift their top leg and extend the hip to the top leg can fall behind the lower leg
2. If the lower leg does not reach the plinth then this indicates IT band tightness
314
How is Thomas test performed?
1. Place the patient in supine with their popliteal crease at the end of the bed and legs hanging off the end
2. Ask the patient to bring one knee up to their chest and hold it there
3. If their contralateral leg comes off the bed then this indicates short hip flexors or hip flexor contracture
315
What is the patella tap test?
This is where you squeeze the hamstring muscles and then tap the patella. A delayed sound after hitting the patella indicates the patella has had to move through inflammatory exudate to hit the femur and make a sound.
316
What is the patella apprehension test?
This is where lateral pressure is applied to the patella. If vastus medialis tenses in response to this movement this indicates patellar instability.
317
How do you perform an anterior draw test?
1. Place the knee in around 70 degrees flexion
2. Interlock hands in the popliteal crease and pull towards you
3. Laxity and translation of the tibia indicates laxity or damage to the ACL
318
What is Lachman's test?
This is similar to the anterior draw test except you perform it in around 20 degrees knee flexion, stabilisng the femur with one hand and pulling the tibia with the other. A lack of a firm stop indicates ACL laxity or damage.
319
How can tibial tuberosity position be used to identify PCL pathology?
With both knees in 70 degrees flexion, if one PCL is higher than another then the lower one likely has PCL pathology.
320
How can you test for PCL laxity?
1. Place one hand on the lateral aspect of the leg below the knee and one hand on the medial aspect above the knee
2. Push the knee in opposite directions
3. High levels of translation are indicative of PCL pathology
321
What is McMurray's test?
This is a test for meniscal damage
322
How do you perform McMurray's test?
1. With the patient in supine place the hip into 45 degrees flexion
2. Apply valgus tilt by turning the heel inward and the foot outward (for medial meniscus) or varus tilt by turning the heal outward and the foot inward (for lateral meniscus)
3. Make an arc from flexion to extension with hip adduction (for medial meniscus) or abduction (for lateral meniscus)
4. This movement will trap any meniscal tears and cause pain or locking
323
What is Noble's compression test?
This is a test for iliotibial band friction syndrome
324
How is Noble's compression test performed?
1. In supine, place the patient's knee in 90 degrees flexion
2. Palate and apply pressure to the lateral femoral condyle and ask the patient to extend their knee
3. Pain at 10-20 degrees of remaining flexion indicates that the IT band may be rubbing against the lateral aspect of the knee joint
