Knee, Ankle and Foot Flashcards
Q Angle
Normal = 15°
Measured by creating one straight line from ASIS to center of patella and another straight line through the tibial tuberostiy and senter of the patella.
Note: Females typically have a increased Q angle.
Genu Valgum
Knees close together and feet farther apart (“knock knees”) - Increased Q angle
(Gum holding knees together)
Genu Varum
Knees farther apart and feet close together (“bowlegged”) - Decreased Q angle
(Bottle of Rum between the knees)
Genus Recurvatum
Seen from sagital plane, knees have a backward curvative (hyperextension)
Knee Anatomy
Patella Medial and lateral tibial plateau Medial and lateral femoral condyle Medial and Lateral meniscus Medial and lateral collateral ligaments Anterior and posterior cruciate ligaments Tibial tuberosity Proximal fibular head Popliteal fossa Anserine and prepatellar bursa
Ankle/Foot Anatomy
Medial and lateral malleolus
Deltoid, anterior and posterior talofibular ligamnets
Flexor and extensor hallucis longus tendons
Fibularis longus, brevis, tertius tendons
Flexor digitorum longus tendon
Tarsal Bones
Metatarsal bones
MTP, DIP, PIP
Tarsal Bones
Talus, Clacaneus, Navicular, Cuneiforms 1-3, Cuboid
Knee Flexion
Biceps femoris (long and short head), semimembranosis, semitendinosis, gracili, gastrocnemius, plantaris, sartorius, popliteus ms.
145-150°
Knee Extension
Rectur femoris, vastus lateralis, vastus medialis, vastus intermedius ms.
0°
Knee Internal Rotation
10°
Knee External Rotation
10°
Plantarflexion
Soleus, gastrocnemius, plantaris, posterior tibialis, flexor hallucis longus, flexor digitorum longus ms.
55-65°
Dorsiflexion
Anterior tibialis, extensor hallucis longus, extensor digitorum longus ms.
15-20°
Supination Coupled Motions
plantarflexion, adduction, inversion
Pronation Coupled Motions
dorsiflexion, abduction, eversion
Ankle Inversion
Anterior tibialis, posterior tibialis ms.
20°
Ankle Eversion
Fibularis longus and brevis ms.
10-20°
Phalanges Motions
Flexion, extension, adduction, abduction, circumduction
L1-L3 Dermatome
Anteromedial thigh
L4 Dermatome
Patella and Big Toe
L5 Dermatome
Anterior Leg, Ankle and Big Toe
S1 Dermatome
Lateral Leg and Lateral phalanges (5th digit)
S1-4 Dermatome
Posterior Thigh
Valgus Test
Patient supine with the knee flexed to 30°. Physician
supports the lower leg with one and other hand placed on the lateral aspect of the patient’s knee. Apply a medial force to the proximal tibia while abducting the lower leg. This test is done at 30° flexion and neutral (0°).
(+) Test: Increased laxity, soft or absent endpoint, pain
Indication: Medial collateral ligament (MCL) disruption. If positive at 0° with knee fully extended, indicates more serious injury, possibly joint capsule
Varus Test
Patient supine with the knee flexed to 30°. Physician
supports the lower leg with one and other hand placed on the medial aspect of the patient’s knee. Apply a lateral force to the proximal tibia while adducting the lower leg. This test is done at 30° flexion and neutral (0°).
(+) Test: Increased laxity, soft or absent endpoint, pain
Indication: Lateral collateral ligament (LCL)
disruption. If positive at 0° with knee fully extended, indicates more serious injury, possibly joint capsule
Anterior Drawer Test
Patient supine with knee flexed to 90°. Examiner sits on the patient’s foot and grasps the proximal tibia with both hands, pulling the tibia anteriorly.
(+) Test: Excessive translation
Indication: ACL insufficiency (injury/tear)
Lachman’s Test
Patient supine. Examiner places cephalad hand on the distal thigh, superior to patella. Caudad hand grasps the proximal tibia. Flexing the knee to 10-30°, the examiner uses his caudad hand to pull the tibia anteriorly while the cephalad hand stabilizes the
thigh. This is a more sensitive test than Anterior Drawer.
(+) Test: Increased laxity, soft or absent end point
Indication: ACL insufficiency (injury/tear)
Posterior Drawer Test
Patient supine with knee flexed to 90°. Examiner sits on the patient’s foot and grasps the proximal tibia with both hands, translating the tibia posteriorly.
(+) Test: Excessive translation
Indication: PCL insufficiency, posterior capsular injury or
disruption (injury/tear)
Reverse Lachman’s Test
Patient supine. Examiner places cephalad hand on the distal thigh, superior to patella. Caudad hand grasps the proximal tibia. Flexing the knee to 10-30°. The proximal hand stabilizes the femur while the distal hand pushes the tibia posterior. This is a more sensitive test than Posterior Drawer Test
(+) Test: Increased laxity, soft or absent end point
Indication: PCL insufficiency/posterior capsule injury or
disruption (injury/tear)
McMurrary’s Test for Medial Meniscus
Patient is supine, with hip and knee flexed. Examiner uses caudad hand to control the ankle and cephalad hand placed on distal femur. Examiner rotates the tibia into external rotation and applies a valgus stress, then
continues the leg into extension.
(+) Test: Pain or a palpable click during extension.
Indication: Possible medial meniscus tear
McMurray’s Test for Lateral Meniscus
Patient is supine, with hip and knee flexed. Examiner uses caudad hand to control the ankle and cephalad hand placed on distal femur. Examiner rotates the tibia into internal rotation and applies a varus stress, then
continues the leg into extension.
(+) Test: Pain or a palpable click during extension.
Indication: Possible lateral meniscus tear
Apley’s Grind Test - Compression Test
Patient prone with knee flexed to 90°. Examiner uses downward force on the foot to provide a compressive force on the meniscus, while rotating the foot internally and externally.
(+) Test: Pain with rotation and/or compression
Indication: Possible meniscal injury, collateral ligament
injury, or both
Apley’s Grind Test - Distraction Test
Patient in same position as for the compression. Examiner stabilizes the thigh, then applies upward traction to the leg while rotating it (traction reduces meniscal pressure, but increases ligamentous strain)
(+) Test: Pain with distraction and rotation
Indication: Possible collateral ligament damage
(+) Test: Relief of pain with distraction
Indication: Possible meniscus injury
Patellar Laxity Test
One hand above and one hand below the joint.
Thumbs placed against the medial side of the patella. Examiner pushes the patella laterally, assessing ROM.
(+) Test: Sense of apprehension or instability
Indication: Possible previous patellar dislocation or severe
instability
Patellar Apprehension Test
When testing laxity to the point of restriction, ask the patient if the maneuver provokes any discomfort or sense of instability.
(+) Test: Sense of apprehension or instability
Indication: Possible previous patellar dislocation or severe
instability
Patellar Compression (Grind) Test
Patient supine and knee extended. Provide compressive load to the patella with one hand while moving the patella medial and lateral.
(+) Test: Pain with compression
Indication: Possible inflammation, chondromalacia, or injury to the patellofemoral articular surfaces
Patella-Femoral Grinding Test
Compress patella caudally into trochlear groove and instruct patient to tighten quadriceps against resistance.
(+) Test: Crepitus or pain
Indication: roughness or articulating surfaces (ie: chondromalacia)
Patellar Glide Test
Patient sitting or supine will slowly extend and flex the knee, while patient notes quality of the articular motion. Placing hand lightly over the patella can increase sensitivity of the test.
(+) Test: Palpable or audible crepitus, pain or catching of the patella.
Indication: Possible damage to the articular surface.
Anterior Drawer Test of Ankle
Grasp posterior calcaneus with one hand and distal tibia/fibula with the other hand, monitoring anteriorly at the anterior talus. Provide anterior force on calcaneus while stabilizing the distal tibia/fibula. Normal springing of calcaneus back to neutral should occur.
(+) Test: Pain, no springing, excessive motion/laxity
Indication: ATF ligament pathology/tear (lateral ankle
sprain)
Talar Tilt Test
Grasp distal tibia/fibula with one hand and inferior calcaneus with the other, blocking motion of the calcaneus on the talus. Invert the talus to evaluate ROM.
(+) Test: Laxity, increased ROM, or pain
Indication: Calcaneofibular ligament pathology/tear, also tests some ATF (lateral ankle sprain)
Eversion Test
Grasp distal tibia/fibula with one hand and plantar surface of the mid-foot with the other hand. Evert the foot to evaluate ROM.
(+) Test: Laxity, increased ROM or pair
Indication: Deltoid ligament pathology (medial ankle sprain)
Squeeze Test
Wrap hands around leg proximal to the ankle, contacting distal tibia/fibula with both thenar eminences. Squeeze for 2-3 seconds, then rapidly release.
(+) Test: Pain at syndesmosis
Indication: Syndesmosis pathology (high ankle sprain)
Cross Leg Test
Patient crosses affected ankle over opposite knee. Apply pressure to distal fibula of affected leg
(+) Test: Pain at distal ankle
Indication: Syndesmosis pathology (high ankle sprain)
Thompson Test
Patient prone with foot off the table. Squeeze the patient’s calf. Observe for plantarflexion.
(+) Test: Absence of plantar flexion
Indication: Achilles tendon rupture
Homan’s Sign
Patient laying or seating with knee extended. Dorsiflex the patient’s foot. Can apply lateral compression to calf. Can also observe accompanying signs of edema, erythema, and warmth of lower leg. Would need to order a Venous Doppler to rule out clot.
(+) Test: Pain with dorsiflexion
Indication: thrombophlebitis or acute deep vein thrombosis (DVT)
(Not always performed clinically due to potential risk of
embolus)
Moses Sign
Patient seated or supine with knee slightly flexed or extended. Induce an anterior compression on the gastrocnemius muscle into the posterior aspect of the tibia (compresses the calf towards the tibia).
(+) Test: Pain with anterior compression
Indication: Deep vein thrombosis of the posterior tibial veins
(Not always performed clinically due to potential risk of
embolus)
Inverion (Lateral) Ankle Sprain
Accounts for 80-85% of all ankle sprains. Mechanism of injury is usually ankle inversion with plantar flexion.
Ligaments involved: Anterior talofibular, calaneofibular, posterior talofibular.
Symptoms include swelling, tenderness, and ecchymosis over the involved area.
High Ankle Sprain
Accounts for 10% of all ankle sprains. Mechanism of injury is ankle eversion and rotation with some dorsiflexion.
Ligaments involved: anterior inferior tibiofibular and syndesmosis.
Pain is more common on medial aspect with minimal swelling. Pain is worse with weight bearing.
Plantar Fasciitis
Inflammation of origin of plantar aponeurosis. Worse with the first steps of the day, improves throughout the day. Point tenderness of calcaneus noted. Pain also found with passive dorsiflexion. Commonly associated with tight calves, repetitive impact activities, high arches, obesity, new/changes in activities.
Common cause of heel pain in adults.
Morton’s Neuroma
Inflammation and thickening of tissue that surrounds the nerve between toes. Most commonly between 3rd and 4th toes (third web space). Patient feeling like they are walking on a marble. Palpable in web space, which will replicate burning pain. Can have radiation of pain and numbness of toes.
Test: Mulder’s sign - clicking sensation upon palpating with one hand the third web space and other hand compressing the transverse arch together.
Turf Toe
Inflammation and pain at base of 1st MTP. Presents as pain and bruising at base of great toe. Caused by hyperextension of great toe causing damage to joint capsule. Severe cases can damage sesamoids and flexor tendon. Commonly associated with activities performed on hard surface.
Achilles Tendonitis
Inflammation at Achilles tendon. Presents as sharp heel pain and stiffness at mid-Achilles tendon to insertion. Pain is worse with strenuous exercising, better with walking. Micro tears in tendon causes swelling and thickening. Commonly associated with tight calf muscles, sudden change in activity, poorly fitting shoes, incorrect running technique
Diabetic Neuropathy
Complication of diabetes causing gradual loss of nerve fibers, presenting as loss of sensation along with impaired pain, light touch, and temperature sensations.
Complete diabetic foot exam includes pulses, sensation and examining for skin lesions
Monofilament Test
Performed on the plantar aspect of the foot. Physician asks the patient to close their eyes. The monofilament is placed on the first and third pad of toes and at base of first, third and fifth plantar MTP joints. Use enough pressure to cause a slight bend of the monofilament. Test is positive if patient cannot feel the monofilament
Gout
Precipitation of monosodium urate crystals in joint space causing an inflammatory response. Most commonly affects the first metatarsophalangeal joint but
can also affect the mid-tarsal joints, ankles, knees, and/or fingers. Swollen, tender, erythematous, and painful joint upon presentation
Osgood-Schlatter Disease
Osteochondritis of tibial tubercle. Caused by repetitive strain and chronic avulsion of ossification center of tibial tubercle, leading to a separation of proximal
patella tendon insertion from tibial tubercle. Frequently seen in children (10-15 yrs) who participate in active
sports. Presents as swelling of tibial tubercle with anterior knee pain that increases gradually over time. Pain may be reproduced by extending knee against resistance
Ottawa Ankle Rules
System to indicate for ankle series.
Series is indicated for patients who have pain in malleolar zone AND have bone tenderness at posterior edge or tip of lateral or medial malleolus OR are unable to bear weight both immediately after injury and four steps in doctor’s office/emergency department.
If the patient can transfer weight twice
to each foot (four steps), he or she is
considered able to bear weight even if he
or she limps.
Palpate the distal 6 cm of the posterior
edge of the fibula when assessing for
bone tenderness.
Ottawa Rules for Foot
A foot series is only indicated for patients who
have pain in the midfoot zone
AND
Have bone tenderness at the base of the
fifth metatarsal or at the navicular
OR
Are unable to bear weight both
immediately after the injury and for four
steps in the emergency department or
doctor’s office.
