Anatomy and special tests of lower extremity
Hip region
The hip region comprises two (2) bony structures- the acetabulum and femur.
The normal angle of inclination is 115-125 degrees (angel of inclination between femur and acetabulum)- if angle is >125 degree then referred to as coxa valga; if angle is <115 degrees then referred to as coxa varus. Femoral neck angle is positioned anteriorly at a 10-15 degree angle; excessive anterior rotation >25 degrees is anteversion and excessive posterior rotation <10 degrees in retroversion.
The primary movements of the hip are that are:
- Hip flexion/ extension
- Hip external rotation/ internal rotation
- Hip abduction/adduction
The hip joint is a stable synovial joint due to the bony anatomy and strength of ligaments, capsule, and labrum.
- Capsule encloses the entire joint
- Labrum
- Attached to the acetabulum and serves to deepen structure to allow for greater articulation
- Ligaments
- Iliofemoral
- Two (2) bands that originate at anterior iliac spine (ASIS), run medially to distal intertrochanteric line and lateral running to proximal aspect of intertrochanteric line
- Both bands tighten with extension and external rotation; superior band tight with adduction; inferior band tightens with abduction
- Pubofemoral
- Band tightens with extension, external rotation, and abduction
- Ischiofemoral
- Band tightens with medial rotation, abduction, and extension
- Iliofemoral
Other pertinent structures of the hip joint are:
- Zona orbicularis- aids in holding head of femur in acetabulum
- Inguinal ligament- forms tunnel for vital arteries, veins, and nerves in lower extremity
- Bursae- act as fluid-filled sac that provides cushioning and friction reduction between tendons, joints, muscles and bone
Image #49
https://upload.wikimedia.org/wikipedia/commons/0/00/Blausen_0488_HipAnatomy.png
Image #50
https://upload.wikimedia.org/wikipedia/commons/f/f1/Gray339.png
Knee region
The knee region is composed of four (4) bony structures- femur, tibia, fibula, and patella. These bony structures then form three (3) joints- tibiofemoral, patellafemoral, and proximal tibiofibular joint.
Image #51
https://upload.wikimedia.org/wikipedia/commons/b/bc/Blausen_0597_KneeAnatomy_Side.png
The primary movements of the knee that are aided by the three joints of the knee are:
- Knee flexion/extension
Other pertinent structures of the knee joint are:
- Capsule
- Tibiofemoral capsule covers distal femur and proximal tibia- posteriorly divided into medial and lateral sections, anterior cut-out for patella
- Proximal tibofibular capsule is continuous with knee 10% of time
- Ligaments
- Tibiofemoral and patellofemoral joints
- Medial collateral ligament
- Tightened in extension; slackened in flexion
- Prevents internal rotation and provides stability against valgus forces
- Lateral collateral ligament
- Tightened in extension; slackened in flexion
- Prevents external rotation and provides stability against varus forces
- Anterior cruciate ligament
- Prevents anterior displacement of tibia on femur and provides rotation stability
- Posterior cruciate ligament
- Prevents posterior displacement of tibia on femur
- Meniscofemoral ligament
- Aids posterior cruciate ligament in preventing posterior displacement of tibia on femur
- Transverse ligament
- Connects medial and lateral meniscus anteriorly
- Alar fold
- Keeps patella in contact with patella
- Medial collateral ligament
- Proximal tibiofibular joint ligaments
- Anterior tibiofibular ligament
- Reinforces anterior capsule
- Posterior tibiofibular
- Reinforces posterior capsule
- Anterior tibiofibular ligament
- Tibiofemoral and patellofemoral joints
- Menisci
- Function
- Deepen fossa of tibia
- Increased congruency of tibia and femur
- Reduces friction between joints during movement
- Improves weight distribution
- Provides shock absorption and lubrication to knee
- Provide stability to tibiofemoral joint
- Lateral meniscus
- Outer side of joint
- Attached to popitieus and joint capsule
- Stabilizes knee against lateral rotation and tibial rotation
- Medial meniscus
- Inner side of joint
- Attached to medial collateral ligament and joint capsule
- Stabilizes knee against medial rotation and tibial translation
- Function
- Bursae- act as fluid-filled sac that provides cushioning and friction reduction between tendons, joints, muscles and bone
Image #52
https://upload.wikimedia.org/wikipedia/commons/7/7b/Knee_medial_view.gif
Image #54
https://upload.wikimedia.org/wikipedia/commons/d/d8/Gray352.png
Foot and ankle region
The ankle/foot joint is composed of eight (8) articulations which include the talocrural, subtalar, talocalaneonavicular, calcaneocuboid, transverse tarsal, tarsometatarsal, metatarsophalangeal, and interphalangeal joint.
Image #53
https://upload.wikimedia.org/wikipedia/commons/thumb/b/bf/Ankle_en.svg/1920px-Ankle_en.svg.png
Image #55
https://upload.wikimedia.org/wikipedia/commons/b/bd/Blausen_0411_FootAnatomy.png
The primary movements of the foot/ankle joint are:
- Ankle plantarflexion/dorsiflexion
- Ankle inversion/eversion
Other pertinent structures of the ankle/foot joint are:
- Capsule
- Provides stability to the joints of the ankle/foot
- Ligaments
- Talocrural joint
- Medial collateral ligament- deep and superficial fibers
- Lateral collateral ligament
- Subtalar joint
- Interosseous talocalcaneal ligament
- Lateral talocalcaneal ligament
- Posterior talocalcaneal ligament
- Medial talocalcaneal ligament
- Talonavicular joint
- Plantar calcaneonavicular ligament
- Dorsal talonavicular ligament
- Calcaneocuboid joint
- Medial band of bifurcate ligament
- Medial calcaneocuboid
- Long plantar ligament
- Plantar calcaneocuboid
- Tarsometatarsal joint
- Medial dorsal ligament
- Lateral dorsal ligament
- Cuneonavicular joint
- Plantar ligaments
- Three (3) dorsal cuneonavicular ligaments
- Metatarsalphalangeal joint
- Plantar ligaments
- collateral ligaments
- Interphalangeal joint
- Plantar ligament
- Collateral ligament
- Talocrural joint
- Plantar fascia
- Collagen fibers connecting from medial calcaneus to phalanges
- Fascia tightens during dorsiflexion- leads to supination and inversion
- Bursa - act as fluid-filled sac that provides cushioning and friction reduction between tendons, joints, muscles and bone
Lower extremity range of motion normals
Lower extremity special tests
Hip special test
- Hip scour test
- Patient supine with hip flexed and adducted to the limit of movement; add compressive load
- Tests for general hip pathology and degenerative joint disease
- Positive: reproduction of pain symptoms or apprehension to perform
- Patient supine with hip flexed and adducted to the limit of movement; add compressive load
- Patrick (FABIR) test
- Patient supine, passively flex, abduct, and externally rotate test leg so the foot is resting above knee on opposite leg; then slowly leg down toward the table
- Identifiers dysfunction of hip, specifically mobility dysfunction
- Positive: involved knee is unable to assume relaxed position and/or reproduction of painful symptoms
- Patient supine, passively flex, abduct, and externally rotate test leg so the foot is resting above knee on opposite leg; then slowly leg down toward the table
- Thomas test
- Patient supine; one hip and knee maximally flexed to chest with hold; opposite limb is kept straight on table
- Tests for tightness of hip flexors
- Positive: straight limb flexes and patient is unable to keep this leg straight on leg
- Patient supine; one hip and knee maximally flexed to chest with hold; opposite limb is kept straight on table
- Ober’s test
- Patient side-lying; lower limb flexed at the hip and the knee; passively extend and abduct tested with knee in 90 degrees while slowly lower the limb toward the table
- Tests for tightness of tensor fascia late or iliotibial band
- Positive: uppermost leg remains above horizontal
- Patient side-lying; lower limb flexed at the hip and the knee; passively extend and abduct tested with knee in 90 degrees while slowly lower the limb toward the table
- Ely’s test
- Patient is prone; flex knee of tested limb
- Tests for tightness of rectus femoris
- Positive: hip of tested limb flexes
- Patient is prone; flex knee of tested limb
- 90-90 hamstring test
- Patient position in supine; hip and knee supported in 90 degrees flexion; passively extend knee until end feel encountered
- Test for tightness of the hamstrings
- Positive: knee lacks 10 degrees or greater of knee extension
- Patient position in supine; hip and knee supported in 90 degrees flexion; passively extend knee until end feel encountered
- Piriformis test
- Patient supine with foot tested limb passively placed lateral to opposite limb’s knee with tested adducted
- Tests for piriformis tightness and syndrome
- Positive: tested knee is unable to pass over resting knee or reproduction of pain- pain in buttocks or sciatic nerve pain
- Patient supine with foot tested limb passively placed lateral to opposite limb’s knee with tested adducted
- Trendelenburg test
- Patient standing and asked to stand on one leg; observe for stance leg pelvis
- Tests for gluteus medius weakness
- Positive: stance pelvis drops when in single leg stance
- Patient standing and asked to stand on one leg; observe for stance leg pelvis
Knee special test
- Lachman test
- Patient supine with knee flexed to 20-30 degrees; stabilize the femur and passively translate tibia anteriorly
- Tests the integrity of the anterior cruciate ligament
- Positive: excessive anterior translation on tibia compared to uninvolved limb
- Test has higher sensitivity and specificity compared to anterior drawer test (preferred test)
- Patient supine with knee flexed to 20-30 degrees; stabilize the femur and passively translate tibia anteriorly
- Anterior drawer test
- Patient supine with knee flexed to 45-90 degrees; therapist passively translates knee anteriorly
- Tests the integrity of the anterior cruciate ligament
- Positive: excessive anterior translation on tibia compared to uninvolved limb
- Patient supine with knee flexed to 45-90 degrees; therapist passively translates knee anteriorly
- Posterior drawer test
- Patient in supine with knee flexed to 45 degrees; therapist passively translates tibia posteriorly
- Tests integrity of posterior cruciate ligament
- Positive: excessive posterior translation on tibia compared to uninvolved limb
- Patient in supine with knee flexed to 45 degrees; therapist passively translates tibia posteriorly
- Valgus stress test
- Patient supine with knee resting at edge of mat; therapist applies valgus stress to the knee with knee flexed at 0 and 30 degrees
- Tests the integrity of medial collateral ligament
- Positive: laxity and pain compared to uninvolved side
- Patient supine with knee resting at edge of mat; therapist applies valgus stress to the knee with knee flexed at 0 and 30 degrees
- Varus stress test
- Patient supine with knee resting at edge of mat; therapist applies varus stress to knee with knee flexed at 0 and 30 degrees
- Tests integrity of lateral collateral ligament
- Positive: laxity and pain compared to uninvolved side
- Patient supine with knee resting at edge of mat; therapist applies varus stress to knee with knee flexed at 0 and 30 degrees
- Pivot shift test
- Patient supine with knee extended, hip flexed and abducted to 30 degrees and slight internal rotation; therapist holding knee with hand and the foot with another applies valgus force through a flexed knee
- Tests the integrity of the anterior cruciate ligament
- Positive: tibia reduction during the test by iliotibial band
- Patient supine with knee extended, hip flexed and abducted to 30 degrees and slight internal rotation; therapist holding knee with hand and the foot with another applies valgus force through a flexed knee
- McMurray test
- Patient supine with knee maximally flexed; therapist passively internally rotates and extending knee- then moving to externally rotating and extending knee
- Test lateral meniscus (internal rotation) and medial meniscus (external rotation)
- Positive: reproduction of click, popping, or pain in knee
- Patient supine with knee maximally flexed; therapist passively internally rotates and extending knee- then moving to externally rotating and extending knee
- Thessaly test
- Patient standing on involved leg while holding therapist’s hands; patient rotates body and leg internally and externally with knee flexed to 5 degrees and then at 20 degrees
- Test lateral meniscus (internal rotation) and medial meniscus (external rotation)
- Positive: reproduction of click, popping, or pain in knee
- Patient standing on involved leg while holding therapist’s hands; patient rotates body and leg internally and externally with knee flexed to 5 degrees and then at 20 degrees
- Patellofemoral instability
- Patient supine with knee flexed to 30 degrees and quadriceps are relaxed; therapist passively translates the patella laterally
- Test for patellar instability
- Positive: patient expresses apprehension or contracts the quadricep muscle to prevent patellar dislocation.
- Patient supine with knee flexed to 30 degrees and quadriceps are relaxed; therapist passively translates the patella laterally
- Noble compression test
- Patient supine with knee flexed to 90 degrees and hip flexion; therapist applies pressure 1-2cm proximal to lateral femoral epicondyle; with pressure maintaining, patient’s knee is passively extended
- Tests the iliotibial band
- Positive: patient experiences pain over the lateral femoral condyle
- Patient supine with knee flexed to 90 degrees and hip flexion; therapist applies pressure 1-2cm proximal to lateral femoral epicondyle; with pressure maintaining, patient’s knee is passively extended
- Ottawa knee rules
- Apply the Ottawa knee rules to:
- Rule out fracture after acute knee injury
- Refer for imaging with one or more positive answers
- A negative test result states there is an absence of fracture
- If therapist answers yes to any of these questions, then imaging should be done to rule out fracture
- Age 55 years or older
- Isolated patellar tenderness without bone tenderness
- Tenderness of the fibula head
- Inability to flex knee to 90 degrees
- Inability to bear weight immediately after injury
- Apply the Ottawa knee rules to:
Ankle special test
- Anterior drawer test
- Patient supine with foot off edge of mat; ankle in 20 degrees of plantarflexion; therapist translates talus anteriorly while stabilizing lower leg
- Tests integrity of anterior talofibular ligament
- Positive: excessive anterior talar translation and/or pain
- Patient supine with foot off edge of mat; ankle in 20 degrees of plantarflexion; therapist translates talus anteriorly while stabilizing lower leg
- Talar tilt
- Patient side-lying with knee slightly flexed and ankle in neutral position; therapist moves foot into maximal adduction (calceniofibular ligament) and abduction (deltoid ligament)
- Tests the integrity of calcaneofibular ligament
- Positive: laxity and/or pain
- Patient side-lying with knee slightly flexed and ankle in neutral position; therapist moves foot into maximal adduction (calceniofibular ligament) and abduction (deltoid ligament)
- Thompson’s test
- Patient prone with foot off edge of mat; therapists squeezes calf muscle (ankle should plantarflex)
- Tests integrity of Achilles tendon
- Positive: no movement of foot
- Immediate red flag if positive tests occurs- send to emergency room
- Patient prone with foot off edge of mat; therapists squeezes calf muscle (ankle should plantarflex)
- Windlass test
- Weight bearing
- Patient standing on step with toes positioned over the edge with equal weight baring; this causes a passive extension of the first MTP joint
- Non-weight bearing
- Patient seated with knee flexed to 90 degrees; therapist stabilizes the ankle and passively extends the patient’s first MTP joint
- Both tests for the presence of plantar fasciitis
- Patient seated with knee flexed to 90 degrees; therapist stabilizes the ankle and passively extends the patient’s first MTP joint
- Positive in both positions: reproduction of plantar surface pain
- Weight bearing