Physio Charlie

Anterior Drawer

With the patient in supine, apply a posteroanterior force to the tibia with the knee flexed to 90o.

As well as testing the ACL it also tests the posterior oblique ligament, the arcuate-popliteus complex, posteromedial, posterolateral joint capsules, medial collateral ligament and the iliotibial band.

The normal amount of movement is around 6mm; excessive movement indicates injury to one or more of the structures above.

Lachmans Test

This is a modified draw test, carried out with the patient in supine and with the knee flexed (0-30o). This position is close to the functional position of the knee, in which the ACL plays a major role.

Stabilise the femur and apply a posteroanterior force to the tibia.

As well as testing the ACL it also tests the posterior oblique ligament and the arcuate-popliteus complex.

A positive test is indicated by a soft end feel and excessive motion and indicates injury to one or more of the structures above.

Lateral Pivot Shift Manoeuvre

This is the primary test used to assess anterolateral rotary instability of the knee and is an excellent test for ruptures (third-degree sprains) of the ACL.

You are looking for abnormal (excessive) anterior rotation of the tibia on the lateral side relative to the femur. During the test, the tibia moves away from the femur on the lateral side (but rotates medially) and moves anterioly in relation to the femur.

The patient lies supine with the hip both flexed and abducted 30o and relaxed in slight medial rotation (20o).

Hold the patient’s foot with one hand while the other hand is placed at the knee, holding the leg in slight medial rotation. This is done by placing the heel of the hand behind the fibula and over the lateral head of the gastrocnemius muscle with the tibia medially rotated, causing the tibia to sublux anteriorly as the knee is taken into extension.

Lateral Pivot Shift Manoeuvre continued

Apply a valgus stress to the knee while maintaining a medial rotation torque on the tibia at the ankle

The leg is then flexed, and at approximately 30o to 40o the tibia reduces or ‘jogs’ backward.

A positive test is indicated by the patient saying that is what the giving way feels like.

If the test is positive the following structures have probably been injured to some degree: ACL, posterolateral capsule, arcuate-popliteus complex, lateral collateral ligament, iliotibial band.

A disadvantage of this test is that in the apprehensive patient, because of the forces applied during the test, protective muscle contraction may lead to a false negative test.

Active Pivot Shift Test

The patient sits with the foot on the floor in neutral rotation and the knee flexed 80o to 90o.

Ask the patient to isometrically contract the quadriceps while you stabilise the foot.

A positive test is indicated by anterolateral subluxation of the lateral tibial plateau and is indicative of anterolateral instability.

Benjamise et al (2006) 28 studies

Lachman: most valid, sensitivity 85%, specificity 94%

Pivot shift: specific 98% but sensitivity 25%

Anterior draw: sensitivity 92%, specificity 91%

Kostogiannas (2008)

Pivot shift and Lachmans, 25 patients

Positive pivot shift test 3/12 after injury strong predictor of a need for ACL reconstruction

Negative pivot shift 3/12 after injury low risk of surgery

Pins (2006)

Lachmans test is most sensitive

Pivot Shift most specific

Posterior Draw

With the patients knee flexed to 90o, apply an anteroposterior force to the tibia.

As well as testing the PCL it also tests the arcuate-popliteus complex, posterior oblique ligament and anterior cruciate ligament.

Excessive movement indicates injury one or more of the structures above.

Reverse Lachmans

The patient lies prone with the knee flexed to 30o, grasp the tibia with one hand and fix the femur with the other hand.

Ensure the hamstrings are relaxed and then pull the tibia up (posteriorly), noting the amount of movement and the quality of the end feel.

Be wary of a false-positive test if the ACL has been torn, because gravity may cause an anterior shift.

This test is not as accurate for the PCL as the posterior draw test, because when the PCL is torn, the greatest displacement is at 90o.

Godfrey (gravity) Test

The patient lies supine

Hold both legs with the hips and the knees flexed to 90o

If there is posterior instability, a posterior sag of the tibia is seen.

If manual posterior pressure is applied to the tibia, posterior displacement may increase.

Valgus (abduction) Stress Test

Assessment for one-plane (straight) medial instability, which means that the tibia moves away from the femur on the medial side.

Apply a valgus stress (push the knee medially) at the knee while the ankle is stabilised in slight lateral rotation either with the hand or with the leg held between the examiner’s arm and trunk.

The test should be carried out with the knee first in full extension and then slightly flexed (20o to 30o) so that it is unlocked.

It has been advocated that resting the test thigh on the examining table enables the patient to relax more and is easier for the examiner. The knee rests on the edge of the table; the lower leg is controlled by the examiner stabilising the thigh on the table, and the lower leg is is abducted, applying a valgus stress to the knee.

Varus (adduction) Stress Test

An assessment for one-plane lateral instability (i.e., the tibia moves away from the femur an excessive amount on the lateral aspect of the leg).

Apply a varus stress ( push the knee laterally) at the knee while the ankle is stabilised.

The test is first done with the knee in full extension and then with the knee in 20o to 30o of flexion.

If the tibia is laterally rotated in full extension before the test, the cruciate ligaments will be uncoiled, and maximum stress will be placed on the collateral ligaments.

Loss of extension

Loss of flexion

Locked knee

Joint line tenderness

Persistent joint effusion

McMurrays test

McMurray’s Test

Palpate the medial joint line and passively flex and then laterally rotate the knee so that the posterior part of the medial meniscus is rotated with the tibia

A snap of the joint will occur if the meniscus is torn

The joint is then moved from this fully flexed position to 90o flexion so that the whole of the posterior part of the meniscus is tested.

A positive test occurs if the clinician feels a click, which may be heard, indicating a tear of the medial meniscus.

McMurray’s Test

Palpate the lateral joint line and passively flex and then medially rotate the knee so that the posterior part of the lateral meniscus is rotated with the tibia, a snap occurs if the meniscus is torn.

The joint is than moved from a fully flexed position to 90o flexion, so that the whole of the posterior part of the meniscus is tested.

A positive test occurs if the clinician feels a click, which may also be heard, indicating a tear of the lateral meniscus.

Mohan et al (2007)

150 patients

94 trauma, 53 sports related

Joint line tenderness and McMurray test

Medial meniscus: 88% accurate, 98% sensitive and 65% specific

Lateral meniscus: 92% accurate, 92% sensitive and 93% specific

Dial Test

The test is designed to show loss of the posterolateral support structures of the knee.

The patient may be placed in supine or prone, flex the knee to 30o, extend the foot over the side of the plinth and stabilise the femur on the plinth.

Laterally rotate the tibia on the femur and compare the amount of rotation to the good side.

If the test is done in supine you can observe the amount of tibial tubercle movement and compare.

The test is repeated with the knee flexed to 90o and the thigh still on the plinth.

If the tibia rotates less at 90o than at 30o, in isolated posterior lateral (popliteus corner) injury is more likely. If the knee rotates more at 90o, injury to both the popliteus corner and PCL injury are more likely.

Femoral rotation -internal rot is associated with tight ……………band and poor functioning of posterior……………………..

muscle it is commonly found in patient with patella femoral pain.  Enlarged tibial tuberosity is associated with o……………- s……………..

Genu valgum is accociated with lateral tibia torsion and genu varum is associated with …………. ……………………..

Valgus knee are more prone to PF problems and ……………………..compartment problems.  Excessive foot ………………….is a contributing

factor of knee pain.  Enlarged fat pad usually associated with hyper-…………………… knees and poor …………………… control, particularly

eccentric inner range (0-20 degrees of flexion).  Hyper-extended knee (can be associated with ……………………… pelvic tilt and can impinge

the suprapatella bursa

Weight bearing Status

Dynamic posture – gait, squatting,

Observation of Muscle form – strength, length, control

Observation of soft tissue-quality & colour of the skin, swelling, joint effusion, scarring.

Observation of balance – standing on one leg with eyes open/closed (unbalance: proprioceptive dysfunction.

Giving way: indicates instability of the knee, meniscus pathology, chonromalacia, patellar subluxation

Locking: loose bodies, meniscus pathology

Clicking – muscle tendon over bone,

Clunking – instability

Grinding – bone on bone/degeneration

Base of the patella normally lie +/-5mm from the medial and lateral femoral epicondyles when the knee is flexed 20 degrees.

Glide of the patella on quadriceps contraction:

Palpate left and right base of patella and

vastus medialis and lateralis. Ask the

patient extend the knee (contract the quads). If there is a Lateral patella

Glide it indicates a dynamic problem (VMO can be felt to contract after vastus lateralis/weakness)

Patella tilt is calculated be measuring the distance of the medial and lateral borders of the patella from the femur.

Lateral tilt: The distance is decreased on the lateral aspect and increased on the medial aspect, such that the patella faces laterally. (associated with a tight lateral retinaculum, (deep and superficial fibres) and iliotibial band).

Walking:

Climbing stairs:

Descending stairs:

Squatting:

0.3 times the body weight

2.5 times the body weight

3.5 times the body weight

7 times the body weight

Oxford Scale (revision)

0 - No contraction

1 – Flicker of contraction

2 – Full ROM with gravity counterbalanced

3 – Movement against gravity

4 – Movement against gravity with added resistance

5 – muscle functions normally

Isolating Bicep Fermoris

leg laterally rotated

(pointing outwards)

resistance applied down and

inwards

Isolating semi-tend and

semi-mem, leg medially

rotated (point toe inwards),

Resistance applied down &

Out.

Pop Angle

Knee extension should be

within 20 degree of full

Extension

If hamstrings are tight, the

end feel will be a muscle

stretch  

Resist knee flexion

through range

Resist knee extension

through range

Patient lies supine, one knee flexed to

the chest to stabilise the pelvis and flatten

the lumbar spine

Leg lifts of the table =

Tight hip flexors

The angle of the knee should remain at 90

degrees if it extends slightly =

Tight rectus femoris

If the leg abducts as the other is flexed to

the chest it is indicative of a tight =

Illiotibial band

Length: 0-15 degrees

Normal

Strength: Resist

plantar flexion, calf

raise. 

Single leg balance

Timed

- Eyes opened

- eyes closed

Poor Balance = proprioceptive dysfunction.

Single knee bend

Long axis of the femur and the 2nd MT in

neutral lime (+/- 10 degrees)

Reduced control = weak glut med

The knee joint is a synovial bicondylar hinge joint between the condyles of the femur and those of the tibia with the patella sitting anteriorly.

The knee joint satisfies the requirements of a weight-bearing joint by allowing free movement in one plane only combined with considerable stability, particularly in extension

The knee allows flexion and extension in the sagittal plane, it also permits a small amount of rotation of the leg, particularly when the knee is flexed and the foot is off the ground

There are three articulations: two femorotibial and one femoropatellar

The lateral tibial condyle is flatter, shorter from anterior to posterior and more oval than the medial

Plane synovial joint between the circular or oval facet on the head of the fibula and a similar facet on the posterolateral aspect of the undersurface of the lateral tibial condyle

The fibular articular facet faces anteriorly, superiorly and medially, while that on the tibia faces posteriorly, inferiorly and laterally

A fibrous capsule attaches at the margins of the facets on both tibia and fibula, and is strengthened by accessory ligaments anteriorly and posteriorly

The joint surfaces are inclined at an angle greater than 20o, generally the greater the angle, the smaller the surface area of the joint

Rotation at this joint occurs during dorsiflexion of the ankle, especially in horizontal joints

In knee flexion, the fibula moves anteriorly, and in extension, posteriorly

Attached to the tibia immediately anterolateral to the anterior tibial spine

Passes beneath the transverse ligament, blending somewhat with the anterior horn of the lateral meniscus, and runs posteriorly, laterally and proximally to attach to the posterior part of the medial surface of the lateral femoral condyle

Prevents the femur from sliding posteriorly on the tibia, prevents hyperextension of the knee and limits medial rotation of the femur when the foot is on the ground i.e when the leg is fixed

The posterolateral bulk of the ligament is taut in extension, with the anteromedial band lax (and vice versa in flexion)

Attaches to the depression in the posterior intercondylar area of the tibia

Runs anteriorly, medially and proximally, passing on the medial side of the ACL to attach to the anterior part of the lateral surface of the medial femoral condyle

The PCL is shorter and less oblique in its course, as well as being almost twice as strong in tension, than the ACL

Closely aligned to the centre of rotation of the knee joint and therefore may be its principal stabilizer

Prevents the femur from sliding anteriorly on the tibia, particularly when the knee is flexed

The ACL provides approx 86% of the restraint to anterior displacement, and the PCL about 94% of the restraint to posterior displacement of the tibia on the femur

Rupture of the ACL results in very little increase in the anterior draw, while rupture of the PCL results in a posterior draw of up to 25mm

The latter is probably due to lack of collateral resistance to posterior displacement and a lax capsule posteriorly

The cruciate ligaments also provide some mediolateral stability

Strong flat band, 8-9cm long

Attaches to the medial epicondyle of the femur, is almost aligned with the tendon of the adductor magnus muscle, bridges superficial to the insertion of the semimembranosus muscle, crosses the medial inferior genicular artery and is crossed by three tendons, sartorius, gracillis and semitendinosus

Passes downwards and slightly forwards to attach to the medial condyle of the tibia and the medial side of the shaft

The most superficial fibres descend below the level of the tibial tuberosity, deeper fibres have a shorter course from femur to tibia, with the deepest fibres spreading triangularly to attach to the medial meniscus

Rounded cord, 5cm long

Attached to the lateral epicondyle of the femur above and behind the groove for popliteus, and passes down to attach to the lateral surface of the head of the fibula in front of the apex, splitting the tendon of biceps femoris as it does so

Cord-like ligament is separated from the lateral meniscus by the width of the popliteus tendon

The menisci are cartilaginous and tough where compressed between the femur and tibia, but ligamentous and pliable at their attachments

The menisci conform to the shapes of the surfaces on which they rest

Firmly attached, larger than the lateral meniscus

Semicircular in shape, with its posterior part broader than then anterior. The anterior horn is attached to the anterior part of the intercondylar area on the tibia immediately in front of the ACL

The posterior horn attaches to the posterior intercondylar area between the PCL posteriorly and the posterior horn of the lateral meniscus anteriorly.

Its entire periphery attaches to the joint capsule

Movements on the concave condyle are restricted as the horns are attached further apart

Attaches with the medial collateral ligament

More easily damaged then the lateral meniscus

Loosely attached

Forms about four-fifths of a circle and is uniform breadth throughout

The anterior horn attaches in front of the intercondylar eminence posterolateral to the ACL with which it partially blends. In this region it is twisted upwards and backwards as it rests on the slopping bone of the tibial condyle

The posterior horn attaches behind the intercondylar eminence anterior to the posterior horn of the medial meniscus. Posterolaterally the lateral meniscus if grooved by the tendon of popliteus, from which it receives a few fibres

Can slide anteriorly and posteriorly on the condyle because the horns are attached close together and the coronary ligament is slack

Not often damaged

More important then the medial meniscus plays an important role in the stability of the knee

Removal Results in early onset of OA

Suprapatellar Bursa

Extends approximately 6cm above the patella between the femoral shaft and quadriceps femoris. Initially it develops as a separate bursa, but soon communicates freely with the joint space

Bundles of muscle fibres, articularis genus, from the deep surface of vastas intermedialus, attach to the upper part of the bursa. They serve to maintain the bursa during knee extension

An infection to this bursa may spread to the knee cavity.

Subcutaneous Prepatellar Bursa

Lies between the skin and the lower part of the patella

Subcutaneous Infrapatellar Bursa

Overlies the patella tendon, lies between the skin and tibial tuberosity

Deep Infrapatella Bursa

Lies between patellar ligament and anterior surface of tibia.

Popliteus Bursa

Between tendon of popliteus and lateral condyle of tibia

Anserine Bursa

Separates tendons of sartorius, gracillis, and semitendinosus from tibia and tibial collateral ligament

Gastrocnemius Bursa

Lies deep to proximal attachment of tendon of medial head of gastrocnemius

Semimembranosus Bursa

Located between medial head of gastrocnemius and semimembranosus tendon

Flexion 135 degrees

Bicep Femoris, Semi-membranosus, semi

tendinosus, sartorius, popliteus,

Gastrocnemius

Extension 0 degrees, -5 hyperextension

Rectus Femoris, vastus intermedius,

vastus medialis & lateralis

Medial rotators of the Tibia

Semi-membranosus, semi-tendinosus,

sartorius, popliteus

Lateral rotators of the Tibia

Bicep Femoris

Origin

Insertion

Quadriceps tendon of the patella

Action

Extends the knee and flexes the hip

Innervation

femoral nerve L2-L4

Arterial Supply

Lateral circumflex femoral artery

Origin

Anterio-lateral surface of proximal

2/3 femur

Insertion

Quadriceps tendon

Action

Extends the knee

Innervation

Femoral nerve L2-L4

Arterial Supply

Lateral circumflex femoral artery

Origin

Interochanteric line, inferior greater

trochanter, gluteal tuberosity

lateral lip of linea aspera,

Insertion

Lateral margin of the patella

Action

Extends the knee

Innervation

Femoral nerve L2-L4

Arterial Supply

Lateral circumflex femoral artery

Origin

Intertrochanteric line,

linea aspera, medial

supracondyler line

Insertion

Medial border of Patella

Innervation

Femoral nerve L2-L3

Arterial supply

circumflex femoral artery

Orgin

ASIS

Insertions

Upper medial surface

of the tibia

Action Flexes and laterally rotates

the hip joint.

And flexes the knee

Innervation Femoral nerve (L2,

L3, L4)

Arterial Supply femoral artery

Origin

Inferior ramus of pubis

Insertions

Upper aspect of

medial shaft of tibia

Action

Adducts the hip and flexes

the knee

Innervation

Obtutator nerve L3, L4

Artery Supply Obturator artery, medial

Circumflex femoral artery,& muscular

branches of profunda femoris

artery

Origin

Long head-ischial

Tuberosity

Short head – Linea

aspera & lateral

supracondylar ridge

Insertion

Head of fibular, lateral

tibial condyle

Action

Flexes & laterally rotates the knee,

long head extends the hip

Sciatic nerve L5, S1-S3

Origin

Ischial tuberosity

Insertions

Posterior aspect of he

medial tibial condyle

Action

Extends the hip, flexes & medially rotates the knee

Sciatic nerve, L5, S1, S2

Origin

Ishial tuberosity

Insertions

Medial surface of the

proximal tibia

Action

Extends hip

Flexes & medial rotates

the knee

Sciatic nerve L5, S1, S2

Origin

Lateral condyle femur

Insertion

Proximal aspect of the medial posterior tibia

Action

Knee flexion. Unlocks the extended

knee by medially rotating the tibia

on the femur

Tibial nerve L4, L5, S1

Origin

Lat head – posterior aspect of lateral

fem condyle

Med head – posterior aspect of

medial femoral condyle

Insertion

Posterior surface of calcaneum

Action

Knee flexion and foot plantar

flexion

Tibial nerve, S1, S2

Origin

Lateral supra condylar line

above lateral head of gastro

Insertion

Medial border of tendo achilles

& posterior surface of the

calcaneum

Action

Plantar flexer of ankle and

flexes knee

Tibial nerve S1,S2

Borders

Lateral

Biceps femoris

Lateral head of gastro/plantaris

Medial

Semi-mem, Semi-tend, medial head

of gastronemius

Contents

popliteal artery, which is a continuation of the femoral artery

popliteal vein

tibial nerve

common peroneal nerve

Six or seven

popliteal lymph nodes are embedded in the fat

Pes Anserinous (the goose’s foot)