Lower extremities exam 2 Flashcards
genu varum aka
bowed legs
what is genu varum caused by
increased stretching force on lateral joint structures
genu valgum aka
knock knees
genu valgum caused by
increased stretching force on medial joint structures which can cause degeneration of lateral meniscus
genu recurvatum aka
hyperextended knees
genu recurvatum is often seen in which athletes
swimmers
genu recurvatum is at risk for what
ACL and PCL injury b/c contact b/w patella and femur can cause hyperextension
what does normal patellar alignment look like
the patella is aligned within the trochlea with the center of the femur
patella alta def
high riding patella, aka long patella tendon
patella baja
low riding patella, short patella tendon
squinting patella
medially positioned patella, creates problems with tracking
squinting patella caused by what
femoral anteversion and tibial internal rotation
what can be used to treat squinting patella
j-brace or patella tape
frog eyed patella def
lateral and high riding, creates tracking problem
frog eyed patella may be caused by
femoral retroeversion and tibial external rotation
what is the largest seasmoid bone
patella
what 3 purposes of patella
increased mechanical efficiency for quads, protect anterior portion of knee, absorb and transmit joint’s reaction forces
what are the 4 main anterior muscles acting on the knee
vastus lateralis, vastus intermedius, vastus medialis, rectus femoris
where does sartorius cross
at the hip to the knee
where does the IT band cross
at the lateral part of the knee
which hamstring muscle inserts at the fibula
biceps femoris
3 hamstring (posterior) muscle groups
semiteninosis: medial, semimembranosus, bicep femoris: lateral
what are the 3 medial adductors acting on the knee
adductor longus, adductor brevis, adductor magnus
what makes up the pes anserine muscle group
gracilis, sartorius, semitendinosus
what are 6 functions of the meniscus
deepen articulation and fill gaps when increase in load, improve lubrication for surfaces, provide shock absorption, increase passive joint stability, limit extremes of flexion and extension, serve as proprioceptive organ
what shape is the medial meniscus
c shape
what shape is lateral meniscus
o shape more round
if there is a tear in the red zone is the tissue more or less likely to heal on its own
more likely to heal on its own b/c more vascularization
MCL anatomy
medial epicondyle of femur connects to medial condyle of the tibia
LCL anatomy
lateral epicondyle of femur connects to head of fibula
posterolateral corner palpation
yes, you can find it; important for providing stability against forces throughout the knee
what is included in the posterolateral corner
popliofibular ligament, popliteus complex, arcuate ligament, fabella
where is suprapatella bursa located
b/w quad tendon and femur
where is prepatella bursa located
b/w patella and skin
what is the most commonly injured bursa of knee
prepatella bursa
deep infrapatella bursa
b/w patella tendon and tibia
superficial/subcutaneus intrapatella bursa
b/w patella tendon and skin
pes anserine bursa
b/w pes anserine group tendons and tibia
medial plica def
fold in synovial membrane, feels like a ridge, found medially kn knee
what is
ideal ROM of knee extension
0 deg
what is ideal ROM of hip flexion
135 deg
what is ideal ROM hip extension
30 deg
what is ideal ROM knee flexion
135 deg
what muscles are involved in knee flexion
quads, sartorius, gracilis, plantaris, popliteus, grastroc
what muscles are involved in knee extension
rectus femoris, vastus medialis, vastus intermedialis, vastus lateralis
4 pulses of lower leg
popliteal, posterior tibial, dorsal pedal
DTR of knee
L4= patella
where does LCL insert
fibular head
when doing girth measurements where does the 0 deg mark go
right on the joint line
what measurements should be done above joint line
5, 10, 15 cm
what is Q angle
b/w ASIS, midpoint of patella, tibial tuberosity
what is Q angle used for
quantify line of pull of quads and patellar tendon
normal Q angle for men and women
13 men, 18 women
what does a high Q angle create a risk factor for
ACL injury, especially in women
2 tests used for swelling of knee
sweep and ballotable patella test
sweep test+ test
reformation of edema on MEDIAL side
sweep test perform
apply pressure to knee on one side to get the fluid to move and bulge
what does sweep test indicate
swelling of knee
ballottable patella perform
one hand pushes fluid inferiorly towards the patella and the other hand pushes fluid superiorly towards the patella
+ test ballottable patella
bouncing, bobbing, floating of patella
what does ballottable patella test indicate
joint effusion
4 tests for patellofemoral dysfunction
clark’s sign, patella apprehesion, patellar tilt, medial and lateral patella glide
clark sign aka
c-sign
clark’s sign perform
one hand cups patella and other hand applies gentle downward pressure while patient is contracting quads
+ clark’s sign
pain and inability to hold quad contraction
what does clark’s sign indicate
patella femoral dysfunction or chondromalacia patella
is clark’s test usually reliable
sort of, can produce false positive
patellar apprehension test which direction does patella slide
laterally
+ patellar apprehension test
guarding of quads during contraction
patellar apprehension test indicates
laxity of medial retinaculum
+ patellar apprehension test may indicate
predisposition to subluxation/dislocation of patella
patellar tilt test description
grasp patella w/ index finger and thumb elevating lateral border
+ patellar tilt test
more than 15 deg = hypermobile and less than 0 deg hypomobile
what does 0 deg patellar tilt indicate
tightness of lateral restraints, more than 15 deg may predispose to anterior knee pain
medial and lateral patellar guide test description
supine with bolster under the knee and flexed 30 deg
how to perform medial and lateral patellar glide
move patella medial and laterally
+ medial and lateral glide test
medial: movement of 1-2 quadrants
lateral: movement of 0.5-2 quadrants
medial hypo and hypermobile of knee means
tightness of lateral retinaculum, laxity of lateral restriants
lateral hypo and hypermobile of knee means
tightness of medial restraints and patellofemoral ligaments, laxity of medial restraints
plica tests
medial plica test and stutter test
medial plica test description
flex knee 90 deg, internal rotate tibia, move patella medially and palpate capsule
+ medial plica test
reproduction of symptoms
when may clinican feel plica during medial plica test
around 45-60 deg flexion
stutter test description
cup hand over patella and patient extend knee
+ stutter test
irregular motion b/w 40-60 deg as plica passes medial condyle
what does stutter test look for symptoms of
irregular motion/stutter NOT pain increase
collateral ligament tests
valgus and varus stress tests
valgus stress test description
one hand supports medial tibia and then other grasps the knee laterally
+ valgus stress test
laxity, increase quality at end point, pain compared w/ uninvolved limb
what is the best position for testing valgus test
flex knee 25 deg to isolate MCL
varus stress test description
one hand on lateral portion of tibia and other hand grasps knee and applies varus force
varus stress test +
laxity, decrease quality of endpoint, pain increases
what ligament does varus stress test
LCL
what is best position for varus stress test
25 deg flexion
3 ACL tests
Lachman’s, modified lachman’s, anterior drawer
2 rotary ACL tests
slocum, pivot shift
what is best test for ACL
Lachman’s
what is position for knee to be in for Lachman’s
20-25 deg flexion
how is lachman’s test performed
draw tibia anteriorly while posterior pressure is applied to stabilize femur
+ Lachman’s test
increase amount of anterior tibial translation compared w/ opposite limb or lack of firm endpoint
lachman’s test indicative of
ACL sprain/tear
modified lachman’s test description
place bolster like towel under knee to assist in stabilizing femur
anterior drawer test description
hip flex 45 deg, knee extend 90 deg, tests ACL
anterior drawer test perform
draw tibia anteriorly, index finger used to palpate hamstring tendons and ensure they’re relaxed
+ anterior drawer test
increased amt anterior tibial translation compared w/ opposite limb or lack of firm endpoint
compare lachman’s and anterior drawer test
both for ACL. Lachman’s better clinical values. Anterior drawer= easier to perfrom
slocum test set up
knee flexed 90 deg, tibia internally rotated 25 deg to test lateral capsule and tibia externally rotated to test medial capsule
slocum test +
increased anterior translation or lack of firm endpoint
anteriolateral instability= damage to
ACL, LCL, IT band, politeus, lateral meniscus
anteriomedial instability=damage to
MCL
pivot shift test description
patient supine w/ hip passively flexed to 30 deg, maintain 20 deg internal tibial rotation, increases force of internal rotation when knee is flexed
pivot shift test +
tibia reduces or subluxes as the leg is flexed in 30-40 deg
what does pivot shift test indicate
anterolateral rotary instability or ACL tear
what are 2 PCL tests
posterior drawer and godfrey’s/posterior sag test
+ posterior drawer test mean
increased posterior tibial translation and lack of firm endpoint
posterior drawer test indicates
PCL sprain
how to perform posterior drawer test
grasp tibia and put thumbs on both sides of patellar tendon, palpate hamstring tendons to make sure they are relaxed, push tibia posteriorly
what will posterior drawer test feel like if PCL is sprained
it will feel empty
posterior sag test/ godfrey’s test + test
unilateral displacement of tibial tuberosity
posterior sag test perform
lift lower legs and hold them parallel to the table so the knees are flexed at 90 deg, observe tibial tuberosities
what does posterior sag test indicate
PCL sprain
external rotation/dial test positioning of pateint
patient should be prone
dial test set up
knee flexed 30 deg then 90 deg and externally rotate the lower leg
+ dial test
increase in external rotation greater than 10 deg compared w/ opposite side
what does a difference of knee flexionat 30 deg but not at 90 deg for dial test indicate
injury of posterolateral corner of knee
what does a difference of knee flexion at 30 and 90 deg for dial test indicate
trauma to PCL and related structures
what does a difference in knee flexion at 90 deg but not 30 deg indicate for dial test
PCL sprain
3 miniscal tests
McMurray’s, Apley’s compression/distraction, Thessaly test
which meniscal test has the best clinical values
thessaly
positioning of patient for McMurray’s test
patient supine
set up for McMurray’s test
one hand supports lower leg, thumb and index finger are posteromedial and posterolateral on joint line, valgus stress applied when knee is flexed its available ROM
+ McMuray’s test
pop, click, lock knee
McMurray’s test indicates
meniscal tear
apley’s compression/distraction test positioning
patient prone w/ knee flexed at 90 deg
how is apley’s compression/distraction test performed
apply axial load to tibia w/ IR and ER of tibia, distract tibia away from femur while rotation is happening
+ apley’s compression/distraction test
pain during compression that is eliminated during distraction
what does apley’s test for
meniscal tear
thessaly test set up
patient stand on one leg at a time, flex knee to 5 deg and rotate body to internally and externally rotate femur on the tibia, repeat at 20 deg
+ thessaly test
joint line pain, clicking or locking
2 IT band tests
noble’s compression and ober;s
noble’s compression test set up
patient laying on side, 90 deg flexion, 45 deg hip flexion, knee supported and pressure applied while flexing and extending knee
+ noble’s compression test
pain under thumb, common at 30 deg
what does + noble’s compression test indicate
IT band friction syndrome
ober’s test set up
patient side lying w/ knee flexed to 90 deg, one hand stabilizes pelvis and other supports lower leg, abduct and extend hip
+ ober’s test
thighs remain abducted
ober’s test indicates
IT band tightness: predisposing patient to IT band friction syndrome and/or lateral patellar malalignment
wilson test set up
patient seated w/ knee flexed 90, actively extends knee w/ tibial IR for a few seconds, do ER of tibia after pain is felt
wilson test + test
pain during extension w/ IR that is relived by ER
what does wilson test indicate
osteochondral defect or osteochondritis dissecans on medial femoral condyle
myositis ossificans def
calcification of bone deposits in muscle
what causes myositis ossificans
inflammatory response to quad contusion
tx myositis ossificans
ROM exercises, NSAIDs, refer for imaging
s/s myositis ossificans
decreased ROM, pain, swelling, tender
quad strain most common muscle
rectus femoris
MOI quad strain
muscle overload, sprinting, kicking, improper warm up
s/s quad strain
immediate pain, discoloration, pain w/ extension, pain w/ flexion, swelling
tx quad strain
avoid stretching in early stages especially for 48 hours post-injury
hamstring strain MOI
usually rounding curve or muscle overload
s/s hamstring strain
immediate pain, grabbing back of leg, swelling, pain w/ extension
tx hamstring strain
avoid stretching in early stages, RICE, NSAID
popliteal strain MOI
hyperextension
popliteal strain s/s
pain w/ hyperextension, pain w/ initiation of knee flexion, IR, behind knee
popliteal strain tx
modify activity, RICE, NSAID
hamstring tendonitis location on leg
can be proximal or distal
MOI hamstring tendonitis
insidious, overuse, repetitive activity
s/s hamstring tendonitis proximal
pain in gluteal fold, tender, pain w/ long strides
s/s hamstring tendonitis distal
clicking behind knee, pain w/ knee flexion
popliteus teninitis MOI
insidious onset, overuse
risk factors politeus tendinitis
excessive pronation, posterior knee instability
s/s popliteus tendinitis
pain in fossa radiating to LCL, pain when running downhill, swelling, crepitus, pain w/ knee flexion
tx popliteus tendinitis
strengthening hip musculature, RICE, NSAID
pes anserine tendinitis MOI
run, cycling, insidious, overuse, knee flexion
s/s pes anserine tendinitis
pain at medial tibial plateau, anterior inferior medial knee pain, crepitus, swelling, pain w/ knee flexion
pes anserine tendinitis tx
ratio of stretching and strengthening, RICE, NSAIDS
def fat pad contusion/impingement
pad is impinged b/w femur and tibia
MOI fat pad contusion
hyperextension, direct blow
s/s fat pad contusion
pain on side of patella tendon, swelling
most commonly injured bursa
prepatella bursa= housmaid’s knee
MOI bursitis
direct contact, falling on knee, kneeling for increased duration
s/s bursitis
pain, swelling, redness
medial plica syndrome def
inflammation of medial plica, friction caused by rubbing medial femoral condyle
MOI medial plica
trauma to knee, overuse, insidious
s/s medial plica
anteromedial knee pain, click, pop, lock
+ test medial plica
medial synovial plica, stutter
what does medial plica sometimes look like
meniscal tear
tx medial plica syndrome
ultrasound, laser, injection
popliteal/baker’s cyst description
fluid filled cyst behind knee
MOI popliteal/baker’s cyst
meniscal tear, arthritis, accumulation of fluid
s/s popliteal cyst
bulge behind knee, tightness, inability to fully flex
IT band friction syndrome def
friction b/w IT band and lateral femoral condyle
MOI IT band
insidious, overuse, downhill running
risk factors IT band syndrome
IT band tightness, genu varum, excessive pronation
s/s IT band syndrome
pain lateral femoral condyle, pain w/ stairs, radiate to IT band
+ tests for IT band
noble compression, ober
who is IT band friction syndrome most common in
runners, cyclists
patella tendonitis MOI
insidious, overuse, excessive jump/run
risk factors patella tendonitis
patellar maltracking
s/s patella tendonitis
pain inferior of patella w/ knee extension, tight quad, tight IT band
tx patella tendonitis
improvement of jump/landing, good ratio of stretching and strengthening
patella tendon rupture
overload of extensor mechanism, rapid quad contractions
risk factors for patella tendon rupture
previous tendonitis, tendon degeneration, steroid injections
s/s patella tendon rupture
immediate pain, displacement of patella, swelling, pop
treatment patella tendon rupture
immobilize, reffer
which knee condition should you use diagnosis of exclusion
patellofemoral pain syndrome
MOI patellafemoral pain syndrome
change in surface, activity level or intensity
risk factors patellafemoral pain syndrome
increased Q angle, patella alta or baja, female
s/s patellafemoral pain syndrome
anterior pain, clicking, giving out, pain w/ glide
+ patellafemoral pain syndrome tests
clarke’s sign, ober’s, patellar tilt
tx patellfemoral pain syndrome
strengthening hip and knee muscles
chondramalacia patella condition def
softening, roughening, degeneration of articular surface of patella
MOI chondramalacia patella
patellar misalignment, direct or repetitive trauma
s/s chondramalacia patella
anterior knee pain, crepitus
+ chondramalacia patella test
clarke’s
tx chondramalacia patella test
modify activity, strengthen hip and knee muscles
patellofemoral instability/subluxation MOI
direct trauma, knee extension
risk factors patellofemoral instability
shallow groove, excessive Q angle, hypermobile patella, female
s/s patellofemoral instability
sharp pain, knee gives out, deformity, swelling
+ test patellofemoral instability
patella tilt test, patellar apprehension
tx patellofemoral insability
reduce, immobilize, refer, brace
patellar dislocation MOI
lateral blow, rapid change of direction w/ foot
risk factors patellar dislocation
patella alta, history of previous problems
s/s patellar dislocation
immediate and sharp pain, deformity, swelling, pain
tx patellar dislocation
immobilize, reduce, refer
patellar fracture MOI
direct blow, hyperflexion
s/s patellar fracture
immediate pain, unable to bear weight, deformity, swelling
+ test patellar fracture
tap test
tx patellar fracture
immediate referral, x-ray
osgood-schlatter disease description
apophysitis at tibial tuberosity, usually adolescents
MOI osgood-schlatter
stress on growth plate
MCL sprain MOI
valgus force, ER of tibia
MCL s/s
pain, decreased flexion/extension
tx MCL sprain
brace, RICE, NSAID
LCL sprain MOI
varus force
LCL sprain s/s
pain, swelling, decreased flexion/extension
tx LCL sprain
refer, RICE
ACL sprain MOI
rotation of knee, valgus force, hyperextension
risk factors ACL sprain
female, menstral cycle, increased Q angle
s/s ACL sprain
feeling pop, buckling, pain w/ joint, ACL clutch
allograft vs autograft ACL repair
donor ACL (less common), use piece of body for repair
PCL sprain MOI
direct blow to anterior tibia that drives tibia posteriorly, hyperflexion, hyperextension
PCL sprain usually happens
car accident or falling on knee
s/s PCL sprain
pain w/i knee joint, may not pop
is PCL usually surgical
no, usually not surgical
rotary insability
multiple major structures involved
straight insability
one major structure involved
what test is used to differentiate b/w rotary and straight instability
slocum test
knee dislocation def
rupture of at least 3 of major ligaments: ACL, PCL and at least one more
MOI knee dislocation
hyperextension, rotation, varus force
s/s knee dislocation
pain, deformity, popping, non-weight bearing, swelling
tx knee dislocation
immobilize and immediate transportation to hospital
risk of knee dislocation
neurovascular injury
meniscus tears MOI
tibial rotation, hyperflexion, degeneration
s/s meniscus tear
pain along medial or lateral joint, click, lock, pop, pain w/ flexion/extension
OCD description
fracture of articular cartilage and underlying bone
MOI OCD
repetitive trauma, compressive force, rotational force
s/s OCD
increased pain w/ weight bearing, pain decreased w/ rest, joint line tenderness
tx OCD
modify activity, unload brace, surgery
osteoarthritis MOI
repetitive stress, poor mechanics, injury history, gradual onset
osteoarthritis risk factors
female, obesity, FH
s/s osteoarthritis
pain in morning, baker’s cyst, compensatory gait
tx osteoarthritis
injection for lubrication, knee replacement surgery
femur fracture MOI
direct blow
femur fracture s/s
immediate and severe pain, muscle spasm, deformity
tx femur fracture
immobilize and transport to hospital
