Week 2 Flashcards
passive accessory movements of the tibiofemoral joint
- AP tibiofemoral joint
- PA tibiofemoral joint
- TFJ > medial glide
- TFJ > lateral glide
- internal and external rotation of the tibia on the femur (passive physiological)
passive accessory movements of the superior tibiofibular joints
- AP and PA superior tibiofibular joint
- can also be used as a clearing test
passive accessory movements of the patellofemoral joint
- patellofemoral glides (medial, lateral, cephalad, caudad) - clearing test as well
- medial patellofemoral tilt
functional muscle testing
- inner range quads (IRQ) or Active straight leg raise (ASLR)
- examination of qaudriceps buld, activation of VMO and patellar tracking - assessed in PFPS
-MMT - MLT
special orthopaedic tests for the knee - stress tests for the ligaments
stress tests for the ligaments
- medial collateral ligament (MCL)/valgus test
- lateral collateral ligament (LCL)/varus test
special orthopaedic tests for the knee - PCL
stress test for the PCL
- Posterior Sag test (PCL)
- Posterior Drawer test (PCL)
special orthopaedic tests for the knee - ACL
stress tests for the anterior cruciate ligament (ACL)
- lachman’s test
special orthopaedic tests for the knee - meniscus
- mcmurrays tests
special orthopaedic tests for the knee - patellofemoral
- patella apprehension test
- McConnell test
factors contributing to PFPS
extrinsic
- body mass, surfaces, footwear, volume of work, increased knee flexion, eccentric work
intrinsic
- patella tracking, quadriceps, increased femoral internal rotation
increased hip adduction, pronated foot type, increased knee flexion
patella postioning
- Lateral displacement – closer to lateral femoral trochlea groove
- Lateral tilt – high medial border
- Posterior tilt – Inferior pole moves posteriorly
- Patella alta – high riding patella
Physical examination of PFP
- Observation
- may have swelling present locally or intracapsular, quadriceps wasting (inhibition), patella alta, patella baja, patella tilting
- Consider remote intrinsic risk factors Palpation
- tenderness medial or lateral facets of patella, medial or lateral retinaculum.
Physical examination of PFP
- ROM
- often full ROM, but can be painful with flexion and muscle contraction in extension. Accessory Movements
- PF jt. glide restriction (can be any direction)
physical examination - Functional Assessment
- Assess reported tasks that cause pain
Squat, lunge, step down, running, jumping.
physical examination - other tests
- McConnell’s Resisted Extension in NWB or squat/lunge in FWB
- Exclude other pathology (e.g. meniscus, ligament injury)
- Treatment direction tests can be useful
Patella Tendinopathy
- Overuse condition causing degeneration and local pathology to patella tendon.
- First referred to as “jumpers knee”
- Then “tendinitis” due to injury occurring in non-jumping athletes.
Risk factors of patella Tendinopathy
- Higher body mass index
- Higher waist-to-hip ratio
- Leg length difference
- Lower arch height of foot
- Reduced quadriceps and hamstring flexibility
- Strength - conflicting
MOI of patella tendinopathy
- Repetitive mechanical loading of patella tendon
- Insidious/gradual onset
- Linked to sudden spike in load rather than high chronic workload.
- Insidious/gradual onset
Aggravating factors of patella tendinopathy
- Jumping/Power based movement
- Running
- Change direction
- Decelerating
- Stairs (Can be up and/or down)
- Prolonged sitting
functional tests of patella tendinopathy
- Decline squat (30 deg) (Cook et al., 2000)
- May reproduce pain on lunge, hop, jump and/or eccentric loading.
Hoffa’s Fat Pad impingement
- Infrapatellar fat pad impinged between patella and femoral condyle
- Very pain sensitive structure of knee
- Most commonly seen as acute injury in direct blow or with repeated or uncontrolled extension.
functional testing of Hoffa’s Fat Pad impingement
- May reproduce pain on squat, or loaded extension and/or hyperextension
Adolescent Knee pain- Osgood Schlatter’s Disease
- Osteochondritis at growth plate of tibial tuberosity
- Caused by rapid growth of long bones (growth spurt) in combination with repeated contraction of quadriceps muscle.
- Usually associated with repeated forced knee extension (e.g. running and jumping sports).
- Pain on palpation of tibial tuberosity
Adolescent Knee pain- Sinding Larsen-Johansson Syndrome
- Similar condition to Osgood Schlatter’s
- Affects inferior pole of patella at proximal attachment of patellar tendon
- May have slight swelling and “lump” under patella
Pain on palpation of inferior pole of patella
lateral knee pain - common
- iliotibial band friction syndrome
- lateral meniscus abnormality
medial knee pain - common
- medial meniscus
- OA of the medial compartment of the knee
- PFS
posterior knee pain - common
- baker’s cyst
- knee joint effusion
- reffered pain
- lumbar spine
- PF joint
- neural mechanosensitivity
- biceps femoris tendinopathy
Iliotibial Band Friction syndrome
- Overuse injury presenting as lateral knee pain
Richly innervated fat pad may be source of pain as its compressed under the band (Fairclough etal, 2006)
MOI of Iliotibial Band Friction syndrome
- Insidious onset
- Often related to cycling or running
- May be related to sudden change in session load (duration or intensity)
May be related to involvement of downhill activity or cambered courses
special tests- Iliotibial Band Friction syndrome
Ober’s test (tightness ITB) + passive flexion
Degenerative Meniscal Lesions
- Degenerative meniscal tears occur as a result of long term loading and resultant stress.
- Generally have a complex pattern and predominantly affect posterior horn and midbody.
- Often horizontal in nature
- Associated with articular cartilage changes
OA and degenerative meniscal tears share many same risk factors and biological processes.
degenerative meniscal lesions - special tests
- McMurray’s test
- Steinmann Displacement Test
Knee Osteoarthritis
- major cause of pain and locomotor disability worldwide.
- present clinically in widespread variation and stages.
Affects medial and lateral TFJ and PFJ
- present clinically in widespread variation and stages.
Clinical presentation of OA
Observation
- Joint effusion, often chronic thickened synovial fluid
- Antalgic postures e.g.: reduced weight bearing
- Consider biomechanical risk factors: valgus/varus
- Muscle imbalance (atrophy)
Functional Testing and Gait
- Often presents with abnormal gait (limp)
○ Decreased hip extension on stance
○ Decreased knee extension on stance
○ Decreased ankle dorsiflexion on stance
○ Decreased knee flexion during swing
Range of Motion
- Restricted ROM actively and passively
○ commonly lacks terminal extension ROM and flexion ROM
- Associated pain, may have painful catch during range depending on area of chondral wear, crepitus.
Muscle Tests
- Muscle imbalance (tightness, weakness)
Passive Accessory Movements
- Accessory glides limited, reduced quality
- Distraction may relieve, compression aggravate
Special Tests
- Ax knee ligs for instability
- Meniscal tests often not performed due to joint derangement
Palpation
- Tenderness locally to medial +/- lateral tibiofemoral joint line **
- Hypersensitivity around knee generally
physical examination of acute knee injuries - common
- ACL sprain (rupture)
- PCL sprain
- MCL sprain
- medial meniscus tear
- lateral meniscus tear
- patellar dislocation
- articular cartilage injury
Anterior cruciate ligament
- Named by location on the tibia and cruciate = “crux” (latin meaning for cross)
- Origin: medial aspect of anterior intercondylar area of tibia.
Insertion: posteromedial aspect of the lateral femoral condyle. - 2 bands
○ Anteromedial - taut in flexion and through ROM
-Posterolateral - taut in extension
- Origin: medial aspect of anterior intercondylar area of tibia.
Functional roles of ACL
Role 1
- Resist anterior translation of tibia on femur
- Contributes most at 30 degrees flexion
Role 2
- Resist internal tibial rotation
- Resist abduction/adduction in full extension
ACL injuries
- 60-80% of ACL injuries from non-contact situations
○ Cutting/side stepping manoeuvre
○ One-leg landing
- Functional/dynamic valgus
ACL - MOI and patient interview
Mechanism of Injury
- Non-contact (most common)
○ Deceleration
○ Landing from a jump
○ Pivot (torsion/twist)
○ Hyperextension
- Contact
○ Direct trauma to knee
Patient Interview
- Experience of a “popping sensation”.
- Intense high level pain initially then subsides
- Giving way sensation “my knee dislocated”
Immediate gross effusion
Physical examination of ACL
Observation
- Grossly swollen knee Brush swipe test (presence of intracapsular effusion)
Palpation
- May often be tender lateral joint line from bony contusion.
ROM
- May only lack end ranges of extension and flexion
Clinical Orthopaedic Tests (NB: end feel and laxity; perform asap due to rapid swelling)
- Lachman’s test (Sensitivity: 0.85, Specificity: 0.94)
- Lever Sign (Sensitivity 0.94:, Specificity: 1.0*???? (Lelli et al., 2016)
- Pivot Shift test (Sensitivity: 0.24, Specificity: 0.98). Difficult with acute presentation.
ACL injuries - risk factors
- higher in females
- greater Q angle
- knee hyperextension
Posterior Cruciate Ligament
- Second ligament to make up cruciate complex. Twice as strong as ACL.
- Origin: anterolateral aspect of
the medial femoral condyle - Insertion: posterior aspect of tibial plateau
- 2 bands
○ Anterolateral (taut in mid flexion)
Posterolateral (taut in extension and full flex (>100º)
- Origin: anterolateral aspect of
Functional roles of PCL
Role 1
- Resist posterior slide of the tibia on the femur
- Contributes most at 90 degrees
Role 2
- Resist tibial external
- rotation (90-120 degrees)
Increasing evidence of restraint to internal rotation also
PCL - MOI and patient interview
Mechanism of Injury
Non-contact:
- Hyperextension
Contact (Direct Trauma):
- Sports (tackle or collision)
- MVA (dashboard knee)
- Fall onto bent knee.
Patient Interview
Acute:
- Vague presentation
- May have mild effusion
- Posterior knee pain and/or pain with kneeling
Sub Acute:
- Poorly localised knee pain
- Pain deceleration or with inclines
- Pain with full stride running
Patellofemoral symptoms from increased anterior femoral translation
Physical examination of PCL
Observation
- May have mild to moderate effusion, depends on capsule integrity
Palpation
- Often non specific
ROM
- Vague posterior pain in mid-late flexion ROM and EOR extension.
Special Tests (NB: end feel and laxity)
- Posterior drawer test (Sensitivity: 0.22-1.00. Specificity: 0.98)
- Posterior sag test (Sensitivity: 0.46-1.00, Specificity: 1.00)
- External Rotation Recurvatum test (Sensitivity: 0.22-0.39, Specificity: 0.90)
Medial Collateral Ligament
- Broad, thick banded extracapsular ligament that communicates with medial joint capsule
- Attachment to medial meniscus via meniscofemoral ligament
- 2 layers: Superficial and Deep (3 rd layer is fascial)
- Origin: medial aspect of medial epicondyle
- Insertion: medial aspect of proximal tibia (posterior to pes anserine insertion)
Functional roles of MCL
Role 1
- Prevents valgus strain/knee abduction
- Limits extension and internal tibial rotation
Role 2
- Resist anterior tibial translation
MCL - MOI and Patient interview
Mechanism of Injury
- Contact
○ Direct valgus force to lateral aspect of knee
○ High energy collisions (multi-ligamentous injury)
- Non contact
○ Valgus stress + tibial external rotation e.g. side step, COD unstable surface, landing from jump.
Patient Interview
- Acute traumatic event
- Reports twisting/valgus motion
- Sharp localised pain to medial aspect of knee
- Localised swelling if isolated injury (extracapsular)
Feeling of instability (floppy with lateral movement)
Physical examination of MCL
Observation
- Localised swelling to medial aspect of knee joint
Palpation
- Specific tenderness at MFC attachment and along ligament to tibial insertion
ROM
- Often pain at terminal extension, pain with flexion >100deg.
Special tests (performed at 0° flexion and 30° flexion).
- Valgus Stress Test (Laxity): Sensitivity 0.91, Specificity 0.49
Valgus Stress Test (Pain): Sensitivity 0.78, Specificity 0.67
Menisci and their function
- Crescent shaped wedges of fibrocartilage on medial and lateral aspects of the knee.
Function- Deepen tibial plateaus > increase congruency > load bearing surface area shock absorb
good blood supply on the periphery, poor in centre
- Deepen tibial plateaus > increase congruency > load bearing surface area shock absorb
Menisci presentation
Mechanism of Injury
- Typically a twisting/shearing motion in weight bearing
- Contact (Sports and Non- Sports Related)
○ external force causing twist/shear + varus/valgus moment
- Non-contact (Sports and Non- Sports related)
○ Cutting, decelerating, or landing from jump.
○ degenerative tear from ADL’s
Physical examination of menisci
Observation
- Presence of intracapsular effusion
Palpation
- Palpable tenderness of joint line: Sensitivity 0.76, Specificity 0.77.
ROM
- Pain and often restriction at end range extension and flexion. Commonly pain through flexion range from >90 degrees.
Special Tests
- McMurray’s test: Sensitivity 0.55, Specificity 0.77
Steinman Displacement test: Sensitivity: 0.48-0.97, Specificity: 0.96 ???
The unhappy triad
- Multi-ligamentous injury – ACL,MCL and Medial Meniscus
- +/- bony pathology – tibial plateau fracture
- O’Donoghue’s triad
- +/- bony pathology – tibial plateau fracture
Patella dislocation
Patellar dislocation may be classified:
1. Single episode - usually due to trauma.
2. Recurrent - when the displacement occurs regularly.
3. Habitual - where the patellar displacement occurs at every knee movement.
Persistent - where the subluxation or dislocation persists and cannot be reduced clinically.
Patellar dislocation - MOI
- Traumatic (Indirect)
○ powerful quads contraction against internally rotated femur e.g. twisting on planted foot, and jumping.- Traumatic (Direct)
○ direct blow to medial aspect of patella e.g fall or collision - Atraumatic
○ ligamentous laxity (hypermobility syndromes
bony abnormalities (genu valgus, external tibial torsion)
- Traumatic (Direct)
Physical examination - patellar dislocation
- Palpable tenderness of medial border of patella and lateral trochlea (crash sites)
- Palpable tenderness of medial retinaculum and MPFL
- Large haemarthrosis
- Apprehension test:
Active (or Moving) Apprehension test: Sensitivity: 1.0 Specificity 0.88
Patella fracture - MOI
- Direct Blow
○ Collision/Tackle
○ Fall onto anterior knee- Forceful contraction of quadriceps
- Retinaculum & vasti disruption
- Forceful contraction of quadriceps
Lateral collateral ligament
- Purely extracapsular cord-like structure
- Orientated posteriorly and laterally from femoral attachment.
- Origin: Lateral epicondyle of femur superior and posterior to groove for popliteus.
- Insertion: Lateral surface of head of fibula.
- very rate
LCL - roles
Role 1
- Restraint varus strain/knee adduction mostly in ext
Role 2
- External rotation tibia
Anterior and posterior translation (large)
Posterolateral corner
- Published studies showing injury to lateral knee involves multiple structures of lateral knee.
- Import to exclude in PCL injuries.
- Includes:
○ LCL
○ Popliteus Tendon
○ Popliteofibular Ligament
○ Arcuate Ligament
○ Oblique Popliteal Ligament
○ Fabellofibular Ligament
○ Popliteomeniscal Ligament
- Posterior Meniscofemoral Ligament
LCL/PCL - MOI
Mechanisms of injury
- Direct blow to the medial aspect tibia in a fully extended knee, with the force directed in a posterolateral direction.
- Hyperextension injury (often non- contact)
- Anterior rotatory dislocations (varus stress and hyperextension)
- Posterior rotatory dislocation (varus stress, posteriorly directed blow to a proximal tibia in flexion, i.e. dashboard injury)
Physical examination of PLC and LCL
Observation
- May have localised swelling and/or bruising.
Palpation
- Diffuse tenderness over the posterolateral aspect and lateral joint line, and localised pain at the fibular head.
Range of motion
- Will often have increased hyperextension +/- increased ER
Special Tests
- Varus Stress test: No reported validity
- Dial Test: No reported validity
External Rotation Recurvatum test (Sensitivity: 0.22-0.39, Specificity: 0.90)
Proximal Tibiofibular joint
- Articulation: between lateral tibial condyle and fibular head.
- Fibrous capsule surrounds articulation.
- Supported by anterior and posterior ligaments.
- Remember common peroneal nerve anatomy.
Communicates with knee joint capsule in 10% of population
