Knee and Ankle Flashcards
What is the knee?
Two articulations in one capsule (much like the elbow)
Tibiofemoral joint and patellofemoral joint
Note: The fibula does NOT articulate with the femur
The articular surfaces of the tibia have two discs called menisci (between the tibia and femur)
Both joints have tendon and ligament support
Medial and lateral
Cruciate (anterior and posterior)
ACL is more commonly torn than LCL and PCL.
MCL hurt when leg bends laterally
Knee movement
2 degrees of freedom: flex/ext and rotation at the tib fib joint
Knee is most stable in Extension (strongest) takes more force but causes more damage
Knee is least stable in flexion (easiest to damage)
Tib Fib rotation
This is an automatic rotation at the end of extension-cannot control it
Results in the “screw home motion” or “locking of the knee”
During extension, the tibia is laterally rotated to lock the knee
To unlock, the tibia must rotate medially or the femur must rotate laterally
In extension, the rotation is NOT voluntary, voluntary rotation occurs only in flexion! (most at 90 degrees)
Only in flexion 15 degrees medial and 45 degrees lateral
Patellar glides or tracks
Moves actively-automatically
Assessed Passively
Distal-Proximal Glide: 8 cm
Mediolateral Glide: 9 cm medial 5 lateral
Measure knee flexion
End feel- usually soft
Can be firm due to tension of
quads
Expected AROM =135-150 degrees
What is functional? 90º
Can be tested in supine or prone (active)
Goniometer placement
Fulcrum-lateral epicondyle of femur
Stationary arm-midline of the femur, in line with greater trochanter
Movable arm-midline of fibula, line up with malleolus
Measure knee extension
Expected AROM = 0º
In children, it may go beyond 0º
In adults if it is beyond 5º (up to 10 ok) it is hyperextension or genu recuvatum
End feel is firm
Position:
supine, heel on top of toes
Ask pt to slightly lift the top foot
Goniometer placement
Fulcrum-lateral epicondyle of femur
Stationary arm-midline of femur
Moveable arm-midline of fibula
Knee extension MMT
Quadriceps femoris
Palpation
The rectus femoris is in the V shaped muscle between the sartorius and tensor fascia latae
Vastus medialis- medial thigh proximal to the patella
Others are too deep
Subject in semi sitting, with hip at 45 degrees, knee at 90 over edge of table
Ask them to extend the leg
5=max
4=mod
3=full ROM
2=sidelying on friction free surface
1=trace
Knee flexion MMT
Hamstrings: bicep femoris, semimembranosus, semitendinousus
Palpation
- Biceps femoris(long head and Short head)
along the lateral posterior thigh,
tendon is proximal to the back of knee
- Semimembranosus-either side of
the semitendinousus tendon
- Semitendinousus-proximal to the knee, posterior on the medial side (follow the cord up)
Position the client in prone
hip at neutral
Hip bent 10 degrees
Flex knee to 90 degrees
5=max
4=mod
3=full range
2=sidelying slide on board
1=trace
Clarke’s Grind Test
For suspected patellofemoral dysfunction
Subject-supine with the knee extend
Place your web space of your hand around the superior patella (do NOT push down),
Ask the client to do a quad set (flex quads), resist the patella
Pain or inability to hold contraction = a positive test
McMurray’s Test
For meniscal tear
Pt is supine and relaxed
Examiner takes leg and places the knee in as much flexion as possible
Grab foot at calcaneus and rotate the heel causing internal and then external rotation
Positive sign-pain, but also listen and feel for clicking or popping over the meniscus
Twist laterally: medial meniscus
Twist medially: lateral meniscus
Apley’s grind test
Also, for meniscal tear
Subject is prone with the knee at 90 degrees
Examiner stabilizes the posterior thigh while compressing the through the heel and rotating the leg
Positive sign-pain
In this same position you can do
distraction
Pain=ligament tear
Anterior and posterior drawer test
Anterior:
Suspected ACL tear or rupture
Warning: this test can yield a false positive
Subject is supine with knee flexed to 90 degrees, stabilize the foot on the table
Grasp the proximal tibia, with thumbs on the anterior femoral condyles and pull with fingers under the knee
Attempt to pull tibia anteriorly (like a drawer)
Positive: more than 6 mm of translation at the front (feel with thumbs),
Can also indicate capsule problems, medial collateral ligament, IT band issues
Posterior:
Suspected PCL tear or rupture
Just like the anterior test, but you push instead of pull
Thumbs on tibial plateau
If translates more than 4-6 cm it’s positive
Sometimes will get the drop back sign just putting the person into position
Functional motion in the knee
What is functional? 90º
Entering a tub
Toileting or sitting in a chair
Climbing stairs
Donning Socks
Putting on pants
Ankle and foot joints
Proximal and distal tibiofibular joints
Talocrural joint
Subtalar joint
Transverse tarsal joint (midtarsal)-made up of 2 joints
Tarsometatarsal joint-distal row of tarsals to the metatarsals
Metatarsophalangeal joint
Interphalangeal joint
Proximal and distal tibiofibular joints
Similar to the radius and ulnar - interosseous membrane
Minimal movement occurs here
Proximal joint-slight rotation
Distal joint-very slight rotation
Measuring dorsiflexion
End feel is firm
Expected AROM= 20º
Position the patient in seating with ankle at 90º
The foot should be neutral, not inverted or everted
Ask the client to move toes toward ceiling
Can test supine, prone for non weight bearing or weight bearing in standing
Goniometer
Fulcrum-over the lateral malleolus
Stationary arm-midline of fibula
Movable arm-parallel to the 5th metatarsal NOT PINKY TOE
Measuring plantarflexion
Expected AROM= 40-50º
Testing position-seated with knee at 90 and ankle at a right angle, with no eversion or inversion
Ask the client to point toes down
Fulcrum-over the lateral malleolus
Stationary arm-midline of fibula
Movable arm-parallel to the 5th metatarsal NOT PINKY TOE
Measuring inversion and eversion
Expected AROM-Tarsal joint (anterior foot)
Inversion (tibial deviation)=0-30 degrees, varies greatly compare sides
Eversion (fibular deviation)=0-25 degrees, varies greatly compare sides
Subtalar joint –rear foot- (think sup/pron) : Inversion-5-15 Degrees, Eversion 5-10 ; fulcrum between malleoli, stationary straight up, moveable down middle of foot
End Feel-firm
Goniometer
Fulcrum=anterior aspect of ankle, midway between malleolus
Stationary arm=midline of lower leg
Moveable arm=midline of 2nd metatarsal
Instruct the client to move
For inversion: to plantar flexion and in(supination)
For eversion: toward dorsiflexion and out
Rearfoot (mid calcaneus)
MMT for ankle and foot
Gastrocnemius and Plantaris Muscle (work together)
Responsible for plantar flexion when knee is extended
Palpation
Gastrocnemius-distal to the knee (calf)
Plantaris - not palpable
Test position:
5, 4 and 3-ask the client to stand flat footed,
then go up on toes
If they can do 7-10 reps through full ROM it is 5
If they can do 4-6 reps through full ROM it is 4
If they can do 1-3 reps it is 3
If they can go through partial range it is 2 OR
In prone with foot off edge of table ask them to point their toe
2=partial range of motion
You can also test 5, 4 and 3 in this position
5 would be full range of motion with max resistance ect.
Can also test in supine with leg straight
Traditional scale
Homan’s sign
Suspected DVT
Tested in supine, seated or prone
Passively extend the knee and dorsiflex the ankle
Pain in the calf is a positive
You can also palpate the calf
Beware if the calf muscle is tight, you might get a false positive
Check both sides
