hip & knee extremity notes sorgenfrey gindl 7.16.10
DESCRIPTION
HIp & Knee Extremity Notes Sorgenfrey Gindl 7.16.10TRANSCRIPT
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Hip & Knee Extremity Notes
By: Glenn Sorgenfrey, D.C.
Modified by: Pamela S. Gindl, D.C., D.C.C.P.
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Lower Extremities Evaluation
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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%
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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
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Lower extremity subluxations
A leg length inequality is not always a
function of an anatomically short leg
or a pelvic misalignment.
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Hip - Evaluation - Overview Case History
Visualization
ROM
Palpation
Static
Motion
Orthopedic tests
X-ray
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Hip - Evaluation Case History
Trauma
Repetitive Use
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Hip Evaluation
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Hip –
ROM
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Hip Range of Motion
Flexion 120
Extension 30
Abduction 45
Adduction 30
Internal Rotation 40
External Rotation 45
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Flexion: 120
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Extension: 30
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Abduction: 45
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Abduction: 45
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Adduction: 30
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Internal Rotation: 40
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External Rotation: 45
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Inguinal Ligament
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Anterior Iliofemoral
Ligament
Pubofemoral Ligament
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Adductor Brevis m.
Pectineus m.
Bursa
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Gluteus Medius
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Gluteus Maximus
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Orthopedic Tests
Fabere-Patrick Test
Hibb’s Test
Thomas Test
Trendelenburg Test
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Fabere-Patrick Test
Acronym for these hip motions
Flexion
Abduction
External Rotation
Extension
3 Parts to the test
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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.
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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.
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Fabere-Patrick Test – 3 Parts
3rd – Stabilize opposite hip then press leg
down toward bench (extension)
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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…
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Hibb’s Test
Test is usually
done to
determine hip
joint pathology
Internal
Rotation
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Hibb’s Test
BUT Can take hip
through
Abduction
Extension
External Rotation
As well as Internal
Rotation
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Hibb’s Test
+ = Pain or inability to perform test
Indication = Hip joint pathology (many
possibilities)
Arthritis
Sprain/strain
Fracture
Tight hip adductors
Etc…
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Thomas Test
Done Passively
Patient holding their own leg
OR
Doctor using thigh to induce hip flexion
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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
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Thomas Test
Patient with this problem will visually present:
If chronic
Flat rear-end
lumbar lordosis
Subluxations – BP, PI
If acute
lumbar lordosis
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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.
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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
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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
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Differential Diagnoses
Osteoarthritis
Bursitis/Hip Pointer
Snapping Hip Syndrome
Piriformis Syndrome
Retroverted Hip
Introverted Hip
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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…
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Obturator Externus
Internal Hip
Bursa
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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
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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
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Snapping Hip Syndrome
Posterior - rare
Biceps femoris tendon catching on lateral
ischial tuberosity
Intra-articular – labral tear, loose body,
subluxation, dislocation, etc..
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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.
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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
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Piriformis Syndrome
Visual Findings:
Foot flare, especially on involved side
Over pronation
Change in gait
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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
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Piriformis Syndrome
Motion:
internal rotation at the hip
external rotation at the hip
Weak:
Hip rotators
Abductors
Hamstrings & gluteals
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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
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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
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In Children
Calve`/Perthes` Disease-osteochondritis of
the femoral head
Slipped Capital Epiphysis
Hip Dysplasia
http://www.hawaii.edu/medicine/pediatrics
/pedtext/pedtext.html
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In Kids – Legg-Calve-Perthes
Disease
Avascular necrosis of the femoral head
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In Children - Hip Dysplasia
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In Kids - Slipped Capital Epiphysis
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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
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Procedure
Hip Traction
Variations can incorporate drops
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Knee - Evaluation - Overview Case History
Visualization
ROM
Palpation
Static
Motion
Orthopedic tests
X-ray
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Knee - Evaluation Case History
Trauma
Repetitive Use
Does the knee:
Lock up
Buckle
Catch
When?
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Knee - Evaluation - Overview
Visualization
Edema
Bruising
Discoloration
Front - Alignment of patella to
anterior tubercle
Back – Swelling in popliteal fossa,
does it pulsate?
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Knee - Evaluation - Overview Palpation
Static
Motion
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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Differential Diagnosis
Complete tear of the quadricep tendon
Fractured Patella
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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
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Patella Traction
Procedure:
Dr’s legs will guide patient’s leg into
extension
Dr’s thumbs guide the patella back into the
groove
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Tibia Posterior
History
Fall/blow/constant pressure on front of tibia
Pain
usually found over the popliteal fossa
also be found under the Patella
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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
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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
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Tibia AM
Fluid motion
lost on valgus stress
present on full extension when doing a valgus
pressure
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Tibia AL
History
Varies
Visualization may show
Patella tracking medially
Toe in
Tibial tuberosity may visualize medial of
normal.
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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.
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Fibula L
History of sprains in the ankle are usually
present.
Differential Diagnosis
Fibular fracture
Lateral collateral ligament damage
Shin splints
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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.
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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
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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
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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