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7/29/13 Palpation Knee By Dr. Erienn e Blanchard , PT Anterior Cruciate Ligament • ACL Tear • ACL Tests • Knee hyperextension and • Knee effusion: sweep test dynamic valgus • KT 1000 • Report a pop or giving way • Lachmans • Poor quad contraction • Anterior Drawer • Decreased superior • Pivot Shift patellar glide • Flexed knee gait • Loss of knee ROM • • • • • • • • • • • Lateral femoral condyle Lateral joint line Fibular head LCL ITB insertion Medial femoral condyle Medial joint line MCL Pes Anserine Inferior pole of patella Patellar tendon • MCL Tests • Valgus stress test 0 deg and 30 deg knee Ylexion • Lateral patellar facet • Medial patellar facet • Medial patellofemoral ligament • VMO insertion Posterior Cruciate Ligament • PCL injury • Fall on knee with foot in PF position, dashboard MVA • Feel for tibial plateaus (not there= + PCL injury) Medial Collateral Ligament • MCL Injury • Hit on the outside of the leg with foot planted, knee in valgus position with landing • Pain on medial aspect of knee • Pain with knee extension • Pain over MCL • Tibial tuberosity • Inferior patellar fat pad • PCL Tests • Posterior Drawer • Posterior Sag (Godfrey’s Sign) • Quad Active LCL & PLC • Lateral Collateral Ligament • Posteriorlateral Corner • Hyperextension and varus stress (usually in • Hit on the inside of the leg conjunction with ACL or with foot planted, knee in PCL injuries) varus position with landing. • LCL, popliteus complex, • Pain on lateral aspect of arcuate ligament complex, knee biceps femoris tendon, • Tests for LCL posterolateral capsular • Varus Stress test 0 deg and • Test: prone ER (dial) test 30 deg Ylexion= Grade I, II, with knee in 90 deg and 30 III. Injury deg Ylexion 1 7/29/13 Meniscal Tears • Traumatic: compression with rotation, knee extension from deep Ylexion, shear force with ACL/PCL injury • Degenerative: shear force (knee OA, ADL) • Pain with squatting, stair climbing, clicking, locking, giving way, effusion, may have “locked” knee. • Tests: • McMurray • Joint line tenderness • Pain with deep squatting • Thessaly Test • Ege’s Test Tendonitis • Quadriceps/Patellar • “jumper’s knee”=patellar • Traction overuse injury • Pain to palpation at inf or sup pole of patella • Decreased Ylexion ROM • Pain with stairs, jumping, squatting. • Weakness/Pain with knee extension muscle testing Others • Quadriceps Contusion • Blow to the thigh • Pain to palpation • Swelling • Loss of knee Ylexion ROM • Poor quad contraction • Pre-‐patellar Bursitis • Kneeling on a hard surface • Blunt trauma • Infections • Swelling/thickening of bursa, possibly pain • Pes Anserine Bursitis/ Tendonitis • Sequelae to MCL injury • Blow to medial knee • Tight hamstrings • ER position of tibia • Pain to palpation over insertion • Generalized Anterior knee pain • Pain increased with activity and decreased with rest • Aggravated by stairs, squatting, kneeling, and prolonged sitting • Quad atrophy: “giving way” (caused by inhibition) • Tracking Issues • Malalignment • Soft Tissue Imbalances Others • Baker’s Cyst • Swelling in popliteal fossa caused by herniation of synovial tissue through posterior capsule wall • Anything that causes intracapsular swelling (OA) • Pain with resisted knee Ylexion Patellofemoral ClassiYication • Patellar Instabilities • Congenital/ malalignment • Traumatic • Patellar instabilities • ITB/Friction Syndrome • Overuse injury caused by friction of ITB against lateral femoral condyle • Tenderness over lateral femoral condyle or Gerdy’s tubercle • Possibly decreased hip abductor strength • + Ober’s Test and Noble’s Compression Test • Common Peroneal Nerve Injury • Results from traumatic injury or compression • Sensory loss around the Yibular head, lateral aspect of leg, dorsum of foot, web space between 1st-‐2nd toe • Inability to DF and EV foot • + Tinel’s Sign Patellofemoral Pain (PFP) • Pain with squatting, kneeling, stairs, prolonged sitting • General anterior knee pain with no speciYic localization • An ache that can become sharp in nature • Stiffness in knee after prolonged positioning • No structural alignment • Gait is normal, no usual swelling, muscle mass may be slightly different • No crepitus and negative apprehension • No signiYicant tenderness • Categories • Decreased Ylexibility, decreased strength, altered neuromuscular control, patellar arthritis/ chondral lesion, patellar fracture 2 7/29/13 Conservative Treatment • ACL/PCL Conservative • Acute • Knee PROM/AAROM • Quad Sets/ SLR • Patella Mobilization • Subacute • Stationary bike • AROM exercises/ stretching • ACL: Quad strengthening 90-‐40 deg range; PCL: quad 0-‐40 range • Return to Function • MCL Conservative • Acute • Minimal valgus force • Gradually work toward full knee extension • Brace locked in ~30 deg Ylexion • Subacute/Return to Fxn • Tx impairments • Gradually add exercises that apply valgus force to knee Surgery • ACL/PCL • Acute (0-‐4 wks) • RICE • Knee PROM/AROM/ • Return to Function (8-‐12 wks) • Full knee ROM, no pain with ADL, knee effusion < 1+, quad index= 60-‐80% AAROM • Increase quad contraction (NMES, quad sets/SLR, pateallar mobility) • Return to Sport (4-‐6 mo to • Subacute (4-‐8/12 weeks) • Knee Ylexion at 90 deg • Aggressive scar mobs • Stationary bike satisfactory graft stability, succesfully completed fxn progression, quad index=80-‐90% 1 yr) • Full knee ROM, Conservative Treatment • LCL Treatment • Acute • Follow non-‐operative ACL rehab • Minimize varus force • Subacute/Return to Fxn • Tx impairments • Gradually add exercises that apply varus force • Correct varus gait Articular Cartilage • Non-‐Operative: • ROM/Ylexibility, quad strengthening, orthotics, unloading brace, NSAIDs. • Surgical • Chrondroplasty: remove loose cartilage Ylaps • Osteoarthritis • Non-‐Op: aerobic, joint ROM/Ylexibility, perturbation training • Operative • Total knee arthroplasty • Cemented: Full WB • Uncemented: Partial WB or toe touch WB • Post Surgery • Acute: CPM, ROM, quad sets • Subacute: stationary bike • Return to Fxn: pt preference 3