Download Pressure pain threshold of Popliteus muscle in knee pain subjects

Pressure pain threshold of Popliteus muscle in knee pain subjects
A
Protocol submitted to
HOSMAT HOSPITAL EDUCATIONAL INSTITUTE
Bangalore
DISSERTATION RESEARCH
By
Zakirhusen V. Moria
M.P.T. 1st year
M.P.T (Musculoskeletal and sports)
Guide: Dr. R. Dev Anand (PT)
1
RESEARCH APPROVAL
Pain pressure threshold of Popliteus muscle in knee pain subjects
Research proposal approved by Institutional ethics Committee
On
19/11/2010
INSTITUTIONAL ETHICS COMMITTEE
HOSMAT HOSPITAL EDUCATIONAL INSTITUTE
BANGALORE -25.
2
CONTENTS
Page No.
1
INTRODUCTION
04
1.1 Background of the study
04
1.2 Statement of the problem
06
1.3 Objective of the study
06
1.4 Hypothesis
06
1.5 Null Hypothesis
06
1.6 Operational Definition
06
1.7 Clinical significance
07
2
REVIEW OF LITERATURE
08
3
METHODOLOGY
10
3.1
Study Design
10
3.2
Study Setting
10
3.3
Inclusion Criteria
10
3.4
Exclusion Criteria
10
3.5
Materials
10
3.6
Sample size
10
3.7
Procedure
11
3.8
Outcome measures
12
3.9
Data analysis
18
4
REFERENCES
5
APPENDIX
19
Appendix I
22
Appendix II
23
Appendix III
26
Appendix IV
27
3
Key word:
Pain pressure threshold-PPT
Popliteus muscle-PM
1 INTRODUCTION
1.1 Background of the study
 PM is a small muscle that runs in the posterior part of the knee. It is a thin , flattened and
triangular shaped muscle which forms the floor of popliteal fossa.It originates on the
lateral surface of the lateral femoral condyle(in front of and below the lateral collateral
ligament origin) and also from the fibular head. It also has a origin stemming from the
posterior horn of the lateral meniscus. The tendon then courses under the lateral collateral
ligament becomes extra-articular before joining its muscle belly, which inserts into
medial to the posterior surface of tibia just above the soleal line.1,2,.3
 Located at the back of the knee, semimembtinosus muscle and overlying semitendinousus
tendon forms the upper medial border of Popliteal fossa.The biceps femoris muscle forms
the upper lateral border. Lower medial and lateral head is formed by gastrocnemius
muscle.
 The PM is believed to have number of functions, made possible by its unique ability to
reverse its origin and insertion , depending upon on whether the femur or the tibia is
fixed.
 PM is a primary, dynamic,transverse plane rotatoy knee joint stabilizer.It is an
important controller of knee rotation during stance phase of locomotion.4
4
 Unlocks the knee joint from its locked position by internally rotating tibia.
 Helps the Postrior cruciate ligament maintain stability by preventing excessive
posterior translation of tibia.
 Prevents excessive external and varus rotation of the tibia during knee flexion.
 Popliteus is referred to the main internal rotator of the knee that is in charge of stabilizing
1.a.: Referred
pattern of are
knees at cutting or stopping. People involved inFig.
frequent
cutting pain
or stopping
trigger
point
PM.
considered to be at higher risk for accumulated micro
strain
of of
popliteus.
Hypertrophy
and adaptive shortness of popliteus associated with rotational malalignment might also
Fig.1 b.:anterior
Site forknee
PPTpain
examination
be found and responsible for the development of Idiopathic
.5
of PM.
 Myofascial pain syndrome (MPS) is characterized by pain originating from trigger
points at muscle and fascia associated with muscle spasm, tenderness, motion restriction,
fatigue, and sometimes autonomic dysfunction of the related region.6
 Myofascial pain of Popliteus presents as pain in the back of the knee when crouching and
running or walking , especially going downhill or downstairs. Movement examination
will show that resisted flexion and resisted medial rotation is painful posterior. 7
 Knee dysfunction subjects report one or more of the following symptoms such as:
Painful knee flexion-extension or difficulty in completing final degrees of flexion ROM or Pain
during weight bearing flexion-extension activity or difficulty in maintaining fully flexed position
for longer time period. 8 The PM dysfunction may primarily exhibit a lack of knee extension and
external rotation on femur. This may be attributed to
1. The PM may be hyperactive in the presence of a poorly functioning quadriceps muscle
group. The key role of PM is to control posterior tibial translation during movement.
Inefficient quadriceps will cause overactive of PM to help maintain posterior stability.4
2. A weak hamstring results in hypertrophy of the PM to control tibial rotation in stance
phase.4
3. Hypertrophy due to overuse of the PM caused by to poor biomechanics, running
surfaces or poor training progression.4
5
 Patient with PM tenderness also complains of radiating anterior knee pain .Although
anterior knee pain is very common; the mechanism for the development of anterior knee
pain is still controversial. It has been widely attributed to abnormal quadriceps angle (Qangle), however, it was also proposed that anterior knee pain is a multi-factorial problem
and not only limited to malalignment in the frontal plane. Recently, malalignment in the
transverse plane, namely knee version (KV), was considered to be one of the causes for
the development of idiopathic anterior knee pain (IAKP) that failed to conservative
management.1,5
 Pressure pain threshold(PPT) refers to minimal pressure (force) which induces pain. The
pressure threshold meter (PTM) is a force gauge with a rubber disc of 1cm2 surface. The
instrument has been proven to be useful in clinical practice for quantification of deep
muscle tenderness. Assessment of sensitivity to pain can be diagnosed by PTM.4,9,10
 Travell and Simons (1999) have stated that when PM is involved in the complaint of
posterior knee pain, Patient examination will reveal tenderness of its tendon as well as
region over its tendinous attachment to the femur, sometimes referred to the
Gastrocnemius area. 11
 Pee-Yun lee demonstrated that subjects with Lower External rotation-Internal rotation ratio
will show significantly lower Pain pressure threshold at both Pes Anserinus and PM.5,12
1.2 Statement of problem
 Popliteus dysfunction is often neglected area of clinical examination.
 Knee dysfunction subjects are seldom assessed for Popliteus dysfunction as symptoms
are not clear in Popliteus dysfunction subjects.
1. 3 Objective of the study
 To check PPT of Popliteus muscle in knee pain subjects.
 To compare it with normal leg.
1.4 Hypothesis
In knee pain subjects PPT of PM will be low in comparison with normal knee.
6
1.5 Null hypothesis
PPT of PM is not significantly different from normal knee.
1.6 Operation definition
 Trigger point-patient with active trigger point will show jump sign; an indication of
trigger point location in which patient forcefully pulls away when trigger point is
contacted.
 Non-specific knee pain refers to pain at knee due to non-pathological;soft tissue
dysfunction or biomechanical dysfunction (spasm, length-tension, flexibility, strength
deficit).
1.7 Clinical significance
 By measuring PPT of affected and unaffected side, normal pressure threshold of PM
will be established.
 Strategies to increase the PPT level of affected side can be devised.
 By improving the PPT of subject, it’s easy to treat the Myofascial Dysfunction because
patient will be less apprehensive and will be able to withstand more pressure.
7
2.0 REVIEW OF LITERATURE
Anatomy of Popliteus
The PM is a thin flat, triangular muscle, which forms part of the floor of the popliteal space. It
arises by a strong tendon, from a depression on the outer side of the external condyle of the
femur, and from the posterior ligament of the knee join, and is inserted into inner two-third of the
triangular surface .The tendon of PM is covered by biceps femoris and the lateral collateral
ligament(LCL).12
PM is described as Flattened triangular shaped muscle. Its broad belly attaches medially to the
posterior surface of the tibia above the soleal line, tapering to an apex as it approaches the knee
joint.13
PM originates from the lateral femoral condyle near LCL and inserts along the proximal 1012cm of the poster medial tibial surface forming the floor of the Popliteal fossa.14
Role of Popliteus
John Nyland et al in the year 2005 stated that the Popliteus muscle acts as a dynamic guidance
system for monitoring and controlling subtle transverse and frontal-plane knee joint movement.1
Kun Hwang(2010) in 13 cadaveric study stated that ,PM is internal rotator of leg on femur or an
external rotator of femur upon tibia and also flexor of tibia .When standing with knees flexed , it
contracts to help prevent forward displacement of femur on tibia.20
Basmajian and Lovejoy (1971)studied in 20 subject, found that, with the leg free to move, the
Popliteus muscle was activated by voluntary effort to produce medial rotation of the leg at knee
angles between knee straight and 90° of flexions in the sitting and prone positions.7
Travell and Simons (1992) stated that Trigger point in the knee joint primarily refers to the back
of the knee joint during crouching , running or walking especially during walking downhill or
downstairs. The Trigger point tightness of PM restricts the ROM passive lateral rotation and
weakens active medial rotation of the led with the knee flexed nearly 90o.The relatively small
restriction of full knee extension (usually only 5° or possibly 10°) is often not clearly appreciated
until retesting after treatment. Only then is the full range of normal extension for that patient's
knee identified.16
Musculoskeletal dysfunction and symptoms
Musculoskeletal pain manifest as localized, regional or widespread pain. Musculoskeletal pain is
typically described by patient as a drilling, tight, radiating and diffuse pain sensation with pain
referrals and is often accompanied by deep tissue hyperalgesia or allodynia.
8
Affected muscle often display pain during movements, subjective weakness, increased
fatigability, stiffness and slightly restricted range of motion.6
Algometric measurement of PPT
Andrew A Fischer (1986) did study in 24 male and 26 female subjects established standards for
pressure threshold as well as the reproducibility and validity Pressure algometry over normal
muscles and Standard values validity and reproducibly of Pressure threshold.9
Chesterson, Linda did a study on “Interrater Reliability of algometry in measuring pressure pain
threshold in Healthy humans, Using multiple rater” and concluded that Algometer is highly
reliable measures of PPT with minimal observer error.(ICC=0.91).15
Delaney GA, Mckee AC, did a study on Trapezius muscle for trigger point sensitivity, of right
and left side, for interratter and intrarater reliablity. ICC=0.86 and ICC=0.92 for interratter
reliability and ICC=0.91 and ICC=0.80 for intraratter reliability.24
Ethne L Naussbaum, laurie Downes stated that PPT is a reliable measure, and repeated
algometry does not change pain threshold in healthy muscle with experimental induced DOMS
over 3 consecutive days.The PPT can be used to evaluate the development and decline of muscle
tenderness. Reliability is enhanced when all measurements are taken by one examiner.13
9
3 METHODOLOGY
3.1
Study Design
 Observational design
 Descriptive study
3.2 Study Setting
HOSMAT hospital,Physiotherapy Out patient department.
3.3 Sample size
60 subjects
3.4 Inclusion Criteria
 Non-specific knee pain.
 Tenderness over Popliteal space.
 Pain/Inability to fully flex or extend the knee actively.
 Painful resisted flexion and/or internal rotation.
 Painful and/or deficient passive knee external rotation.
3.5 Exclusion Criteria
 Acute post-operative knee joint.
 Knee join inflammation and gross swelling.
 Neurological impairment.
 Infectious Knee joint.
 Baker’s cyst.
 Popliteal abscess.
 Venous or Arterial disorders.
 Asymmetry in Popliteal space.
10
3.6 Instruments and Materials
 Pressure Algometer (fig no.2)
 1 Cm2 rubber tip for Algometer
 Goniometer
 Visual analogue scale
 Lysholm Knee Scoring Scale
3.7 Outcome measures
 Primary Outcome measure-PPT of PM Affected and Unaffected leg
 Secondary Outcome measure
Range of motion-Knee joint

Functional Impairment-Lysholm knee rating scale

Muscle strength-Manual MMT

Flexibility of Hamstring

Visual analogue scale
11
3.8 Procedure:
Phase I: Familiarization of Algometer by researcher
The familiarization shall be done on normal healthy subjects( students of Hosmat education
institute ,Bangalore). The simple random sample of (N=10) will be done from the aggregate
student list of Hosmat educational institute. 5 male and 5 female students will be selected as
sample.and a written consent shall be obtained. The subjects shall be instructed to assume the
following positions. The algometer probe will lowered at respective muscle spots and subjects
will be asked to report sensation of pain distinct from pressure.This procedure will be repeated
on both the sides and will be performed within a same day.
The aim of the procedure would be to learn to pressurize at constant rate of 5 N/S.6 The
instrument practice session shall be done on 8 different location (muscle spots).
Muscle to be examined
Trapezius
Deltoid
Biceps Brachi
Common extensor origin
1st dorsal interossei
Quadriceps
Hamstrings
Popliteus
Position of the subjects
Sitting with arm relaxed
Location of PPT
Midpoint between C7 and
acromian24
Sitting with arm relaxed
5 cm below acromian
process30
Seated with arm horizontal
1/4th distance from elbow
abduction with elbow full
crease to the lateral border of
extension & forearm
acromian over bicep muscle
supinations
belly30
Supine line with palm on
Most prominent part over
treatment couch
lateral epicondyl17
Sitting with hand supported on Over the belly of 1st dorsal
table
interossei when thumb &
index finger held close
together.15
Supine lying
15 cm above the base of
patella16
Prone with knee 900 flexion
Over the bulk of muscle 16
Prone lying with knee flexed
Over the belly of muscle11
.
to 20
Phase II: Assessment of PPT in knee pain subjects:
Interested subjects coming to the Physiotherapy department will be screened for inclusion and
exclusion criteria by a therapist II (who is not part of in the study). On satisfying the screening,
subject shall be taken into study after taking a written consent
12
Familiarization of subject
After screening,the subject shall be positioned in prone lying with pillow support under
ankle with knees flexed to 200 by therapist II.To familiarize the subject with the Algometer, the
shoulder shall be placed in abduction of 1200 with external rotation to lie on the couch with
elbow in 900 by the researcher. To familiarize the subject with Algometer, common extensor
origin of left forearm shall be marked . Now, the researcher will instruct the subject to report the
subjective feeling of pain distinct from pressure. After that he researcher shall apply the force
through Algometer at constant rate of 5N/s. The subject is instructed when he/she shall feel
pressur/pain on the area tested during algometry. The subject is asked to say “stop” as soon as
sensation of pain distinct from pressure or discomfort will reach and bring to notice to the
researcher. The Algometer shall be retracted and reading of the Algometer shall be recorded as
the PPT of that area. This shall be repeated for 5 trials, to enable the subject better understand the
PPT level
Examination of the PPT of PM
The subject shall now be assessed for PPT in the same position described above. The researcher
shall toss a coin to find the order of the assessment(left or right leg first) , irrespective of the
side affected. The head of the coin shall represent Right side and tail shall represent left. This
ensures the observer bias in minimal. The popliteal space will be palpated by the researcher to
find the trigger point location.PPT of PM is measured at the belly of muscle.The Algometer
probe will be lowered at constant rate of 5 N/s perpendicular to the tissue. The patient will be
asked to say “stop” as soon as sensation of pain is felt. At this point Algometer probe will be
immediately released and reading shall be taken. PPT shall be measured 3 times with rest
interval of 15 seconds.(Fig no.4)
After measuring PPT in one knee, the same procedure shall be performed on the
contralateral knee for 3 repetitions with rest interval of 15 seconds. The average of PPT
shall be used for data analysis.
Following the assessment of primary outcome, the secondary outcome of shall be
assessed.
 Active knee range of motion assessment
Flexion: The subject will be positioned in supine lying and will be asked to bend the knee
as much as he can.
Extension: The subject will be positioned in high sitting at the edge of the bed and with
both the hand on thigh. The subject will be asked to straighten knee as much as he/she
can without lifting the thigh.
Both reading shall be documented by the Goniometer(Fulcrum at lateral epicondyle).29
.
13
 Functional impairment: The subject shall be instructed to fill the Lyscholm knee rating
scale(LKS) and the scores shall be used for data analysis.
 Flexibility:
Hamstring: 90/90 or Active knee extension hamstring flexibility test.28
Procedure: Hamstring: 90/90 or Active knee extension hamstring flexibility test.
Procedure: The subject lies supine with arm across the chest. The hip being tested
shall be passively flexed until thigh is vertical, while opposite leg fully extended.
The subject is has to extend the knee as much as he can.
Measurement: Any deficit in knee joint extension shall be recorded by
goniometer.
 Muscle Strength: Manual muscle testing for grade 4 and grade 5
Hamstring muscle:
Procedure-subject prone with knee 450 flexion. The researcher shall place one hand over
ankle and other at posterior thigh. Resistance is applied in the direction of knee extension
for grade 4 and 5 while subject shall flex his knee while in neutral rotation.29
.
 Visual analogue scale/VAS:(Appendix III)
The subject is instructed to mark his/her level of pain at rest and during aggravating
factor(position/movement).The aggravating factor shall be recorded on the VAS
chart.The subject shall mark on a line which is marked “No pain” on one side and “Max
pain’ on the other side.
14
Flow chart depicting the procedure
Patient with knee pain reported to
Outpatient department in Hosmat
hospital
Screening by other therapist II for
inclusion and exclusion criteria
Subject position in prone lying by
therapist II
Familiarization of subject with
Algometer by the researcher at
common extensor origin
Coin toss randomization for the
side of assessment
PPT of Right knee PM assessed
firstly then left
PPT Left knee PM assessed first then
Right
Primary outcome noted (PPT)
Thorough assessment of Affected
knee (Appendix)
Secondary outcome measure
assessed
Data tabulation
Data analysis
15
3.9 Data analysis
(1) Demographic data: Mean (SD)
(2) Comparison of PPT between affected and unaffected leg using paired t-test.
16
4.0 References
1. Narusha Lachman, Yavuz Kocabey,Joseph Brosky, Remziye Altun,David Caborn,
John Nyland.Anatomy ,Function and Rehabilitation of Popliteus Musculotendinous
complex.J Orthop Sports Phys Ther. 2005;35(3):165-7
2. Stephanie Woodley, Susan Macer. Anatomy in practice: the popliteus muscle. New
Zealand Journal of Physiotherapy 34(1):25-9.
3. Dr Ian Macintyre. Anatomy and Function of the Popliteus muscle. Available from
URL//www.sportsperformancecentres.com
4. Poplitus Muscle and Tendon. The Forum of Benfleet running club.Available from
URL//http://benfleetrunningclub.myfastforum.org/popliteus_muscle_and_tendon_ab
out495.html.
5. Pei-Yun, Lee. The Role of Knee Version in the Development of Idiopathic Anterior
Knee Pain.Available from URL//http://etdncku.lib.ncku.edu.tw/ETT-db/ETDsearch/view-etd?URN=etd-0713105-144721.
6. Hakguder A, Birtane M, Gurcan S, Kokino S, Turan FN. Efficacy of Low Level
laser therapy in myofascial pain syndrome:An algometric and thermographisc
evaluation. Lasers Surg Med. 2003:33(5):339-43.
7. Basmajian JV,Lovejoy JF Jr. Functions of the PM in a man. A multifactorial
Electromyographic study. J bone joint surg. Am 1971;53:557-562
8. Faletti C,De Stefano N, Guidice G, Larciprete M. Knee impingement syndromes.
Eur J Radiol . 1998 May:27 Suppl 1:S60-9.
9. Fischer AA. Pressure algometery over normal muscles.Standard values,validity and
reproducibility of pressure threshold. Pain.1987 Jul:30(1):115-26.
17
10. Fischer AA. Application of pressure algometry in manual medicine.J Man Med
;5:145-50
11. W-L Chen, P-Y Lee, J-S Li, T-h Huang, C-Y Yang and H Peng. The Relationship
among Lysholm score, structural measure, Muscle imbalance and functional
performance in college basketball players with anterior knee pain.Journal of
Biomechanics(January 2007). 40.Supplement 2,pg S335-S335
12. Lee Winson C.C., Zhang,Ming, Arthut . Mak How well different regions of residual
limb tolerate presssure?. Available from URL//http://eprints.qut.edu.au/2953/
13. Nussbaum EL,Dowes L. Reliability of clinical pressure-pain measured on
consecutive days.Phys Ther.1998 Feb;78(2):160-9
14. Fischer AA. Pressure threshold meter: Its use for quantification of tender spots.
Arch phys med Rehabilit Nov;67(11) 836-8
15. Chesterton LS, Sim J,Wright CC, Foster NE. Interrater reliability of algometry in
measuring pressure pain thresholds in healthy humans, using multiple raters.Clin J
Pain.2007Nov-Dec:23(9):760-6
16. Travell JG,Simons D, Baldmore. Myofascial pain dysfunction: The trigger point
manual, vol 2; the lower extremities. Williams and Wilkins 1992.
17. Young A,Stokes M,Iles JF. Effects of joint pathology on muscle. Clinical
Orthopaedics and Related Research .1987 June:(219); 21-27.
18. Stratford P .Electromyography of the quadriceps femoris muscles in subjects with
normal knees and acutely effused knees. Physical Therapy March1982 vol(3)62;
279-83.
19. Flemming Enoch, A Review of the Anatomy . Physiology and Function of Popliteus
Muscle. Avialable from
URL//http://www.kineticcontrol.com/document/clinic/litreview_popliteus_pdf.
18
20. S.English, D.Perret. Posterior knee pain. Curr Rev Musculoskeletal Med. 2010
October:3(1-4):3-10
21. Bill Vicenzino, Jane Brooksbank, Joanne Minto, Sonia Offord, Aatit
Paugmali.Initial effects of elbow taping on painful grip strength and Pain pressure
threshold. J Orthop Sports Phys Ther. Volume 33(7) July 2003
22. Kun Hwang, Kyon Moo Lee, Seung Ho Hun, Sun Goo Kim.Shape and Innervation
of Popliteus muscle. Anat Cell Biol.43:165-68(2010)
23. Reeves JL, Jeeger B, Graff-Radford Sb. Reliability of the pressure algometer as a
measure of myofascial trigger point sensitivity . Pain 1986;24(3);313-321
24. Delaney GA ,Mckee AC. Inter and intra-rater reliability of the pressure threshold
meter in measurement of myofascial trigger point sensitivity . Am J Phys Med
Rehabil 1993;72(3);136-39
25. Graven-Nielsen T, Arendt-Nielsen L.Assessment of mechanisms in localized and
widespread musculoskeletal pain. Nat Rev Rheumatol 2010 Oct;6(10):599-606.
26. Helen J. Hislop, Jacqueline Montgomery, Muscle Testing, 6th edition, W.B.
Saunders.1995.
27. Marta Imamura, Satiko Tomikawa Imamura, Helena H. S. Kaziyama, Rosa Alves
Targino, Wu Tu Hsing, Luiz Paulo Marques de Souza, et al. Impact of nervous
system hyperalgesia on pain , disability and quality of life in patient with knee
osteoarthritis: a controlled analysis. Arthritis and Rheumatism. Vol 59(10)oct 2008:
1424- 31.
28. 90/90 active knee extension (AKE)Hamstring flexibility test. Available from
URL//http.//www.topendsports.com/test/flex-9090htm
29. Cynthia C Norkin, D Joyce White, Measurement of joint motion:A guide to
goniometry.2nd edition. F.A.Davis Company.
30. Florence P. Kendall, Elizabeth K. McCreary, Patricia G. Provance.Muscle testing
and function with posture and pain.5th edition. Lippincott Williams and Wilkins.
19
5 APPENDIX
5.1 Appendix I
HOSMAT College of Physiotherapy
Rajiv Gandhi University
Consent Form
I ________________________________ agree to take part in the research study conducted by
MORIA ZAKIRHUSEN V , Postgraduate student (M.P.T. Musculoskeletal & Sports),
HOSMAT College of Physiotherapy, Rajiv Gandhi University, entitled. “PAIN PRESSURE
THRESHOLD OF POPLITEUS MUSCLE IN KNEE PAIN SUBJECTS”
I acknowledge that the research study has been explained to me and I understand that agreeing to
participate in the research means that I am willing to

Provide information about my health status to the researcher

Allow the researcher to have access to my medical records, pertaining to purpose of the
study

Participate in evaluatory program.

Make myself available for further follow up.(If needed)
I have been informed about the purpose, procedures, measurements and risks involved in the
research and my queries towards the research have been clarified.
I provide consent to the researcher to use the information, video or audio recordings, for
research and educational purpose only.
I understand that my participation is voluntary and can withdraw at any stage of the research
project.
I understand that no monetary benefit will be given for participation in this research study.
Name of the applicant –
Signature
Date
Signature of the researcher
20
Appendix II
Screening form
Name:
Age:
Sex:
Occupation:
Hospital number:
Chief complaints:
Inclusion criteria:
 Pain/ Tenderness in popliteal space
 Non-specific knee pain
 Inability to fully flex/extend knee joint
 Painful resisted flexion and internal rotation
 Painful/deficient of knee external rotation
Exclusion criteria:
 Acute post-operative knee joint
 Gross knee swelling of knee joint
 Knee joint inflammation
 Infectious joint
 Baker’s cyst
 Popliteal abscess
 Venous/Arterial disorders
 Asymmetry in Popliteal space
21
Research study subject number:
Primary outcome chart:
PPT of PM
1st trial
2nd trial
3rd trial
Average
Affected side
Right knee
Left knee
Assessment form:
History:
On observation:
 Attitude of the limb at rest
 Gait pattern
On palpation:
Tenderness
Local temperature
Trigger point identification
On examination:
22
Secondary outcome chart:
Right knee
Left knee
Range of motion
Flexion
Extension
Muscle Strength
Hamstring
Visual analogue scale
Flexibility
Hamstring
Functional
impairment(Appendix IV)
23
Appendix III
Visual Analogue Scale:
No pain
Maximum pain
VAS at rest
No pain
Maximum pain
VAS with aggravating state
24
APPENDIX IV
25
26
27
28