8977 Lecture Notes - Lecture 12: Popliteus Muscle, Avulsion Fracture, Quadriceps Femoris Muscle
3 Jul 2018
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KNEE INJURIES
Common/ Less Likely/ NTBM?
ER goes with extension. IR goes with flexion. Tibia is concave and femur convex – flexion glide the same way.
Objective Examination
Ottowa rules – any findings send for an xray. Findings: aged 55+, isolated tenderness of patella, fibula head tenderness, inability
to flex to 90degrees, OR inability to WB immediately and post (4 steps, weight transfer twice onto each limb).
Articular/Muscular tests
Observe: gait – posture from hips down, walk, Q angle. Skin, deformities and swelling (intra-articular injury will swell above
knee cap in suprapatella pouch).
AROM: flexion and extension supine
PROM: if AROM restricted otherwise over pressure
Resisted: 450 for flexion and about 300 for extension (arm under, rest on opposite knee and other hand on heel).
Neurological tests: S LR with foot 900 or head lift – if pain worsens it’s positive for neural tension. Patella tendon reflex hammer.
Hip quadrant test – supine flex add IR and scoop “C” left to right.
Vascular tests: pedal pulse and posterior knee pulse
Palpation: in 450 flexion. Feel depression below patella, tib plateau, patella tendon, joint lines, fat pad, tib tub, head of fib,
condyles, med hams, lat hams, popliteal fossa (for baker’s cyst) and effusion by swipe or patella tap. Feel all sides of patella in
full ext.
Special tests
ACL – laxity and end feel, pain isn’t usually too great. Do all 3 tests:
Modified Lachman’s – knee under pt’s leg
Pivot shift/reversed pivot shift – flex, IR, valgus knee stress / flex, ER, valgus knee stress
Anterior drawer – 900 sit on pt’s foot
PCL - Posterior sag (feet together see concavity between patella and tib tub – resisted ext and tib moves up).
Posterior draw (start in anterior draw to see if its positive – may already be sagged if start from neutral).
MCL – tuck leg under arm and feel joint line. Push with valgus force at 00 (deep fibres) and 300 (superficial fibres).
LCL - tuck leg under arm and feel joint line. Push with Varus force at 00 and 300.
Meniscus – compression of 1 joint compartment and roll tib against femur.
McMurray’s test – lateral compartment valgus knee, varus ankle begin flex and roll into ext. Medial
compartment varus knee valgus ankle. However not really specific to side – must palpate.
Apley’s grind – prone 900 flex, compress and rotate. If pain decreases when pull up = meniscus or no change
collaterals.
Patellofemoral joint apprehension test – glide patella laterally while stabilising leg. Should have movement but firm end
feel. Dynamic test is glide patella laterally and ask pt to contract quads.
Muscle length tests –
Ober’s test (TFL + ITB) side lying edge of bed, stabilise with your hip, flex knee and extend hip, let gravity
adduct hip. Dynamically test ITB friction by ext and flex in this position.
Hamis (SLR), gastrocs (heel drops or KTW for soleus) and quads (heel to bum).
Posterolateral instability – external rotation recurvatum test (ERRT) ER feet, grab toes and lift until femur almost off
bed, measure distance.
Functional tests: WB, SLB, SLBEC, hop on spot. Then hopping 10m, hexagon hop, hop and hold, run, jump, dodge.
Diagnosis
Rule out less likely and NTBM. Rationalise why you have come to your conclusions.
Intervention (treatment for today and in future)
Acute phase – SPM
Common braces:
Limited ROM - set at joint angle ROM to maintain flex and ext + rigid bars valgus and varus stress preventers.
Zimmer (full brace locked in ext, prevents varus valgus, allows WB during full ext, ideal for patella dislocations.
Non-WB through crutches, walking frames, etc.
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