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KNEE EVALUATIONS

KNEE EVALUATIONS. Knee joint proper ( tibiofemoral joint) Tibia Fibula Femur Patella Patellofemoral joint Femoral condyles articulate with tibial plateaus. The Knee Joint. Extends to 180 º Hyperextension normal Flexes to 140 º With knee flexed 30 º or >

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KNEE EVALUATIONS

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  1. KNEE EVALUATIONS

  2. Knee joint proper (tibiofemoral joint) • Tibia • Fibula • Femur • Patella • Patellofemoral joint • Femoral condyles articulate with tibial plateaus The Knee Joint

  3. Extends to 180º • Hyperextension normal • Flexes to 140º • With knee flexed 30º or > • internal rotation 30º occurs • external rotation 45º occurs The Knee Joint

  4. Sesamoid bone Imbedded in quadriceps & patella tendon Serves similar to a pulley for improving angle of pull (results in greater mechanical advantage in knee extension) The Patella

  5. Surface Anatomy • Patella (A) • Femur (B) • Tibia (C, E – tuberosity) • Joint Line (D) • Fibula (F) • Gerdy’s Tubercle

  6. Internal Knee Anatomy

  7. Internal Knee Anatomy

  8. Menisci

  9. Bursae & Fat Pad of the Knee

  10. Housemaid’s knee

  11. Anatomy – Soft Tissue • Quadriceps – • Rectus femoris • Vastus lateralis • Vastus intermedius • Vastus medialis (& oblique - VMO) • Hamstrings – • Biceps femoris • Inserts primarily on fibula head • Semitendinosus • Semimembranosus • Inserts posteromedially on medial tibial condyle • Popliteal fossa

  12. Muscles • Gracilis, • Sartorius & • Semitendinosus • Common attachment • Pes Anscerine • Iliotibial Band • Gastrocnemius heads – lateral & medial

  13. Knee Movements

  14. Locking mechanism as the knee nears its final extension degrees • Automatic rotation of the tibia externally (approx. 10 degrees) during the last 20 degrees of knee extension • Femoral condyles are a different size • Medial has larger surface area • The tibia glides anteriorly on the femur. As knee extends, the lateral femoral condyle expends its articular distance. The medial articulation continues to glide, resulting in external rotation of the tibia utilizing the lateral meniscus as the pivot point. • ACL & PCL are rotary guides • Forms a close-packed position for the knee joint Screw Home Mechanism

  15. MOI - • Position of lower extremity at time of injury (?foot planted, knee extended) • Previous history • Pain (levels, types, descriptors) • Unusual sounds/sensations “pop, clicking, snapping” • Chronic vs. acute • Location of pain “inside the knee” • Surface • Shoes • Type of activity at time of injury • Painful to walk up/down stairs; any clicking, catching • Did it swell immediately, slowly? • Is the swelling located in the knee or in a pocket? History

  16. Bilateral comparison Gait (limp, walking on toes, do they not want to extend knee, do they keep the knee stiff) Swelling (girth measurements) Discoloration Deformity (squinting patellae, “Frog-eyed” patellae, Patella alta, Patella baja) Genu valgum, genu varum, recurvatum Musculature – defined/mushy Observation

  17. Q-angle • The quadriceps angle (Q-angle) is the angle formed between a line drawn through the tibial tuberosity and the center of the patella and another line drawn from the anterior superior iliac spine (ASIS) of the pelvis through the center of the patella.

  18. Palpation • Tibia – tibial plateau, tibial tuberosity, Gerdy’s Tubercle • Fibula – head • Medial joint line • Medial collateral ligament • Lateral joint line • Lateral collateral ligament • “Windows” • Medial & Lateral femoral condyles & epicondyles • Pes anserine tendon • Semitendinosus tendon • Patella – inferior pole • Patellar tendon • Quadriceps muscle group • Biceps femoris tendon • Iliotibial band • Popliteal fossa • Gastrocnemius heads

  19. On-field vs. Off-field eval • Check for fractures, blood, deformities, neurological • Valgus Stress Test – MCL • Varus Stress Test - LCL • Lachman’s – ACL • Anterior Drawer – ACL • McMurray’s - meniscus Stress/Special Tests

  20. Anterior Drawer Test • (+) Test is increased anterior tibial translation over 6 mm • (+) test indicates: • ACL (anteromedial bundle) • posterior lateral capsule • posterior medial capsule • MCL (deep fibers) • ITB • Arcuate complex • False (-) if only ACL is torn • False (-) if there is swelling or hamstring spasm • False (+) if there is a posterior sag sign present

  21. Lachman’s Test • Best acute ACL test • Best on field test • (+) test is a “mushy” or “empty” end-feel • False (-) if tibia is IR or femur is not properly stabilized

  22. Posterior Drawer Test • Tests for posterior instability • Make sure that there is no anterior translation prior to performing test • (+) Test indicates: • PCL • Arcuate Complex • Possibly ACL ??? Rubenstein, et al 1994 found posterior drawer test 90% sensitive for PCL injury (versus 58% for Quadriceps Active Test & 26% for Reverse Pivot Shift Test). Clinical exam on whole was 96% effective in detecting PCL dysfunction

  23. Godfrey’s Test • Tests for posterior cruciate ligament damage • (+) test is a posterior displacement of the tibial tuberosity

  24. Valgus Stress Test • Assesses medial instability • Must be tested in 0° and 30° • (+) Test in 0° • MCL (superficial and deep) • Posterior oblique ligament • Posterior medial capsule • ACL/PCL • (+) Test in 30° • MCL (superficial) • Posterior oblique ligament • PCL • Posterior medial capsule • Grading Sprains McClure et al 1989 found poor intertester reliability on valgus stress test at 0 and 30 degrees using 3 PT to evaluate 50 patients

  25. Varus Stress Test • Assesses lateral instability • Must be tested in 0° and 20/30° flexion • (+) Test in 0° • LCL • Posterior Lateral Capsule • Arcuate Complex • PCL/ACL • (+) Test in 30° • LCL • Posterior lateral capsule • Arcuate complex • Grading Sprains

  26. Apley’s Distraction Test • Tests for meniscal or ligamentous lesions • (+) test is pain that is eliminated (meniscal injury), or pain that is increased (ligamentous)

  27. Apley’s Compression Test • Tests for meniscal lesions (+) test is increased pain during compression which may increase with rotation in either direction

  28. Check for swelling • Sweep Test, Ballotable Patella • Check ROM Ely’s Test • Check integrity of ligaments & joint stability • Valgus, Varus, Lachman’s, Anterior/Posterior Drawer, Godfrey’s 90-90 Test, Posterior Sag Test, Crossover Test, Slocum Drawer Test, External Rotation Test, Pivot Shift • Check integrity of meniscus • McMurray’s, Apley’s Compression/Distraction, Duck Walk, Bounce home • Check integrity of patella • Patellar Apprehension,Q Angle, Clarke’s Sign, Patellar glide, tilt, rotation • Check integrity of Iliotibial Band • Ober’s Test, Noble’s Compression Test Stress/Special Tests

  29. ? Crutches ? Referral ? RICE Now What?

  30. Osgood-Schlatter’s Disease

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