hip & knee extremity notes sorgenfrey gindl 7.16.10

Hip & Knee Extremity Notes

By: Glenn Sorgenfrey, D.C.

Modified by: Pamela S. Gindl, D.C., D.C.C.P.

Lower Extremities Evaluation

Research

Greenman, D.O. stated in 1989 that

restriction of a major joint(s) in lower

extremity d energy used for walking

1 joint = by 40%

2 joints in same extremity = by 300%

Research

Foot over pronation (if untreated)

leads to:

Tibia & Femur rotation knee

complaints & pelvic unleveling

center of gravity shifts lateral lumbar

curve forms myofascial pain

lumbar disc degeneration

Lower extremity subluxations

A leg length inequality is not always a

function of an anatomically short leg

or a pelvic misalignment.

Hip - Evaluation - Overview Case History

Visualization

ROM

Palpation

Static

Motion

Orthopedic tests

X-ray

Hip - Evaluation Case History

Trauma

Repetitive Use

Hip Evaluation

Hip –

ROM

Hip Range of Motion

Flexion 120

Extension 30

Abduction 45

Adduction 30

Internal Rotation 40

External Rotation 45

Flexion: 120

Extension: 30

Abduction: 45

Abduction: 45

Adduction: 30

Internal Rotation: 40

External Rotation: 45

Inguinal Ligament

Anterior Iliofemoral

Ligament

Pubofemoral Ligament

Adductor Brevis m.

Pectineus m.

Bursa

Gluteus Medius

Gluteus Maximus

Orthopedic Tests

Fabere-Patrick Test

Hibb’s Test

Thomas Test

Trendelenburg Test

Fabere-Patrick Test

Acronym for these hip motions

Flexion

Abduction

External Rotation

Extension

3 Parts to the test

Fabere-Patrick Test – 3 Parts

1st – Flex hip to 90 & press femur into

acetabulum

This motion is also considered to be fluid

motion of the hip joint.

Fabere-Patrick Test – 3 Parts

2nd – Cross leg into “Figure 4” position (abduction &

external rotation)

Allow patient’s leg a chance to relax the muscles to

stress the joint.

Fabere-Patrick Test – 3 Parts

3rd – Stabilize opposite hip then press leg

down toward bench (extension)

Fabere-Patrick Test

+ = Pain or inability to perform test

Indication = Hip joint pathology (many

possibilities)

Arthritis

Sprain/strain

Fracture

Tight hip adductors

Legg-Calve-Perthes Dz

Etc…

Hibb’s Test

Test is usually

done to

determine hip

joint pathology

Internal

Rotation

Hibb’s Test

BUT Can take hip

through

Abduction

Extension

External Rotation

As well as Internal

Rotation

Hibb’s Test

+ = Pain or inability to perform test

Indication = Hip joint pathology (many

possibilities)

Arthritis

Sprain/strain

Fracture

Tight hip adductors

Etc…

Thomas Test

Done Passively

Patient holding their own leg

OR

Doctor using thigh to induce hip flexion

Thomas Test

+ = Opposite hip flexes

This flattens lumbar spine, the tight hip flexor

is revealed by the opposite hip flexing

Indicates = Hip flexor contracture, such as

iliopsoas

Thomas Test

Patient with this problem will visually present:

If chronic

Flat rear-end

lumbar lordosis

Subluxations – BP, PI

If acute

lumbar lordosis

Thomas Test

Patient’s gait will present:

One leg will stride long

This is the side of the tight muscles

Already greater flexion to moving leg forward is no problem

Other will stride short

As the leg on this side goes into flexion as striding forward the opposite hip (with tight flexors) will not allow this leg to move forward as far.

Trendelenburg Test

Dr hold patient’s

crests of ilium ready

to support the patient

if they start to fall

from performing

maneuver.

Patient raises leg

Trendelenburg Test

+ = ilium drops forward and down on lifted leg side

Indicates = hip abductor muscle (gluteus medius) weakness possibly due to:

Polio (age group ~ mid 40’s)

Legg-Calve-Perthes Dz

MD, MS

Hip Dislocation

Gluteal m. paralysis

Subluxation

Differential Diagnoses

Osteoarthritis

Bursitis/Hip Pointer

Snapping Hip Syndrome

Piriformis Syndrome

Retroverted Hip

Introverted Hip

Bursitis

Trochanteric Bursitis – inflammation of 1 of the bursa b: gluteus maximus & minimus & the greater trochanter.

Tx:

Rest, avoid activity that aggravates

Adjust

Soft tissue work

PT, etc…

Obturator Externus

Internal Hip

Bursa

Hip Pointer

Contusion to iliac crest or ASIS

Sometimes including an avulsion or tendonitis

From trauma from sports or MVAs

Tx:

Adjust what’s needed (if side posture keep this side up)

Soft Tissue work, passive ROMs, etc

Protective padding

Snapping Hip Syndrome

Click or snap in the hip upon active hip

motion. Common benign & painless

Lateral/external – most common

ITB catches on greater trochanter

Anterior/internal – common

Iliopsoas catches on iliopectineal eminence

on femoral head, or from iliofemoral

ligament catching on femoral head

Snapping Hip Syndrome

Posterior - rare

Biceps femoris tendon catching on lateral

ischial tuberosity

Intra-articular – labral tear, loose body,

subluxation, dislocation, etc..

Piriformis Syndrome

Definition: Sciatic neuritis due to spasm of

the piriformis m. leading to mechanical

and/or chemical irritation that results in

pain/paresthesia in the distribution of the

sciatic n.

Piriformis Syndrome

Etiology:

Sudden myotactic reflex

Tight external rotators

L5-S1 neurological insult (VS?)

Overuse and/or biomechanical fault (over

pronation)

Fatigue or strain of piriformis m.

Leg length assymmetry

Piriformis Syndrome

Visual Findings:

Foot flare, especially on involved side

Over pronation

Change in gait

Piriformis Syndrome

Palpation:

Tender piriformis in gluteal region

Possible low back pain and tenderness

ROM:

AROM & PROM internal rotation w/pain

Active & passive abduction

Tight hamstrings or atrophy

Piriformis Syndrome

Motion:

internal rotation at the hip

external rotation at the hip

Weak:

Hip rotators

Abductors

Hamstrings & gluteals

Piriformis Syndrome

Treatment

PRICE

Adjust spine & pelvis as needed

Stretch into internal rotation & adduction

US/ice

Correct leg length deficiency/pronation

Home exercises – low back

Osteoarthritis

Common in hip

Some chiropractors say if you keep L3 and

the lumbars subluxation free you won’t

develop hip arthridities

Watch how patient walks

In Children

Calve`/Perthes` Disease-osteochondritis of

the femoral head

Slipped Capital Epiphysis

Hip Dysplasia

http://www.hawaii.edu/medicine/pediatrics

/pedtext/pedtext.html

In Kids – Legg-Calve-Perthes

Disease

Avascular necrosis of the femoral head

In Children - Hip Dysplasia

In Kids - Slipped Capital Epiphysis

Hip Examination

Usually an aching pain patient grasping hip

Fluid motion done with hip telescoping and

Fabere Patrick part I

Fixation is commonly found in internal or

external rotation

Procedure

Hip Traction

Variations can incorporate drops

Knee - Evaluation - Overview Case History

Visualization

ROM

Palpation

Static

Motion

Orthopedic tests

X-ray

Knee - Evaluation Case History

Trauma

Repetitive Use

Does the knee:

Lock up

Buckle

Catch

When?

Knee - Evaluation - Overview

Visualization

Edema

Bruising

Discoloration

Front - Alignment of patella to

anterior tubercle

Back – Swelling in popliteal fossa,

does it pulsate?

Knee - Evaluation - Overview Palpation

Static

Motion

Orthopedic Tests

Appley’s

Compression

Appley’s Distraction

Valgus Stress Test

Varus Stress Test

Drawer Sign

Lachman’s Test

Sag Sign

McMurray’s Test

Bounce Home Test

Patella Femoral

Grinding Test

Apprehension for

Patella

Joint Mouse

This is a free floating body in the joint

Synovial Osteochondral Metastasia

Synovial villa swell and as they expand

they develop a bulbous end which fractures

from the villa then ossifying

Knee Traction Supine

PP: Supine

CP: Dr’s wrist (thumb up into joint space) in

popliteal fossa

Procedure: Flex lower leg over wrist till

either Patient tolerance or joint opens

Best for Tibia Posterior

Knee Traction Prone

PP: Prone

CP: Dr’s thumb web into joint space (fingers

palpate for the joint to open

Procedure: Flex lower leg over wrist till

either Patient tolerance or joint opens

Preferred knee traction move

Best for Tibia Posterior

Knee Traction Limited Flexion

ROM flexion is limited so DC is unable to

perform traction due to amount of flexion

required.

PP: Prone

DS: Kneeling, side of table near feet.

Knee Traction Limited Flexion

Patient’s knee flexed as much as their

limited motion allows with ankle over Dr’s

shoulder

CP: Behind tibia

3 Steps

Knee Traction Limited Flexion

3 Steps:

1. Dr tractions joint open

2. Releases the traction pull

3. Flexes knee further into ROM gained

Repeat steps 1-3 until no more gain in motion or

motion back

Repeat: Traction Release Flex

Patella Traction

Performed for a dislocated patella

History:

usually a blow to medial side of knee pushing patella out of groove

Visually

See it superior & lateral (quadriceps pulls it that way)

Thus keeping the knee in flexion

Swelling around the patella

Patella Traction

X-ray

should be taken to rule out fracture

ROM

Patient unable to extend knee (the quadricep

group will become flexors)

Pain

Present around the patella

Differential Diagnosis

Complete tear of the quadricep tendon

Fractured Patella

Patella Traction

PP: supine (knee is flexed due to

quadriceps contraction)

DS: patient’s ankle between Dr’s legs

SCP: 10 & 2 position at superior aspect of

patella

CP: Dr’s thumbs work well here

Patella Traction

Procedure:

Dr’s legs will guide patient’s leg into

extension

Dr’s thumbs guide the patella back into the

groove

Tibia Posterior

History

Fall/blow/constant pressure on front of tibia

Pain

usually found over the popliteal fossa

also be found under the Patella

Tibia P

Differential Diagnosis

Baker’s cyst

Varicose Veins

Aneurism of the popliteal arteries

ROM

(loss) of flexion

On full flexion by feel like it should “pop”

Fluid Motion

on anterior draw sign indicates Tibia P

Tibia AM

History - varies

Visualization may note

patella tracking laterally

toe out

tibial tuberosity visualized laterally

Pain point

usually over the medial side of knee and medial meniscus

Tibia AM

Fluid motion

lost on valgus stress

present on full extension when doing a valgus

pressure

Tibia AL

History

Varies

Visualization may show

Patella tracking medially

Toe in

Tibial tuberosity may visualize medial of

normal.

Tibia AL

Pain point

over the lateral joint space

should be differentiated from the fibula

Fluid motion

lost on varus stress test

noted on full extension when doing a varus

press.

Fibula L

History of sprains in the ankle are usually

present.

Differential Diagnosis

Fibular fracture

Lateral collateral ligament damage

Shin splints

Fibula L

Pain

Found over the fibular head

May also have pain lateral malleolus

Fluid motion

on P-A and A-P

also on plantar and dorsi flexion of the

ankle.

Knee

Procedures

Patellar Traction

Knee Traction Prone

Knee Traction Supine

Knee Traction Limited Flexion

Tibia AM

Tibia AL

Tibia P

Fibula L

Appley’s Compression

Appley’s Distraction

Valgus Stress Test

Varus Stress Test

Drawer Sign

Lachman’s Test

Sag Sign

McMurray’s Test

Bounce Home Test

Patella Femoral Grinding Test

Apprehension for Patella

Review Hip & Knee

Knee Traction Limited Flexion

Knee Traction Prone

Knee Traction Supine

Patellar Traction

Tibia AM

Tibia AL

Tibia P

Fibula L

Hip Traction

Trendelenburg

Fabere Patrick

Thomas Test

Hibb’s

Appley’s Compression

Appley’s Distraction

Valgus Stress Test

Varus Stress Test

Drawer Sign

Lachman’s Test

Sag Sign

McMurray’s Test

Bounce Home Test

Patella Femoral Grinding Test

Apprehension for Patella

Seated: Supine:

St-Cl Traction Seated St-Cl Traction Supine

St-Cl S G-H Traction Supine

G-H Traction Seated St-Co Traction Supine

A-C PS St-Co S DugasSt-Co Traction Seated St-Co I Drop Arm

G-H I Prone: Yergason’s

G-H P Seated S-T M Prone Dawburn’s

Kocher’s Maneuver G-H P Prone Allen’s Test

Frozen Shoulder Eden’s Test

Wrist Traction (longitudinal) Side Lying: Adson’s Test

Wrist Traction (transverse) S-T M Side Lying Wright’s Test

Elbow Traction S-T L Cozen Test

Ulna P Lift Test

Radius P Carpal Single Thumb Mills Test

Ulna PM Carpal Double Thumb Tinel Tap Test

C-MC 2nd-5th MC-P Traction Phalen’s Test

C-MC 1st I-P Traction English Test