Knee physical examination

Observation

• limb when walking

From behind:

• ankle and knee varus/valgus
• rotation of tibia in relation to femur
• symmetry of gluteal folds and knee creases
• Bakers cyst

From side:

• hyperextension or flexion
• level of patella
• muscle wasting

From in front:

• rotation or deviation of patellae
• rotation of tibia in relation to femur
• swelling
• varus or valgus
• patella height
• quads bulk for muscle wasting

Functional tests and tests for other joints

• squat (may overpress by bouncing)
• lunge
• step up
• walking forwards an d backwards
• jogging on spot
• running
• single leg stance
• squat in single leg stance
• single leg hops
• jumps

Lumbar Spine examination.

• combined movements

Neurological

• muscle power (gastrocs)

SITTING

Observation

• Tibia alignment

Active movements

• active knee extension
• rotation

Resisted movements

• resisted isometric knee extension at 90º flexion and end range extension (critical angle)
• resisted isometric knee flexion (critical angle)

SUPINE LYING

Observation

Palpation

• temperature
• tenderness
• effusion

Effusion tests

• minor effusion (Milking test: milk fluid inferiorly, then from lateral to medial.  Tap fluid back to the lateral side which creates a fullness there)
• moderate effusion (Tap test: for moderate effusion)
• major effusion (Ballottable test: rebounding patella due to underlying fluid).

Neurological

• muscle power, reflexes, sensation as appropriate.

Active movements

• Hip and knee flexion
• Knee extension

Tests for other joints

• hip, ankle (as appropriate)

Neural tissue examination

• SLR and any other tests as necessary

Passive movements

• Flexion/Extension (hip and knee flexion) (overpressure for extension applied to femur above patella, on joint line and over upper end of tibia).
• Internal rotation/External rotation of tibia (in flexion and extension) (can add compression or distraction)

Combined movements

• Extension-abduction
• Extension –adduction
• Flexion-abduction-medial rotation
• Flexion –adduction –lateral rotation

Passive accessory movements

Tibiofermoral joint

• PA tibia (in full extension 90º flexion, full flexion)
• AP tibia (in full extension 90º flexion, full flexion)
• Medial glide/lateral glide tibia ( in full extension, 90º flexion, full flexion)
• AP Femur

PATELLOFEMORAL JOINT

Observation

• alignment, slide, tilt, rotation, A/P tilt

Passive Accessory

• Distraction/Compression
• Medial glide/lateral glide
• Oblique glides
• Longitudinal cephalad/Longitudinal caudad
• Rotation (done in comparable range)

Superior Tibiofibular joint

• PA/AP (fibula on tibia)(can use in compression)
• cephalad/caudad

Orthopaedic tests for specific structures

* as appropriate

• Medial and lateral collateral
• Anterior and posterior cruciate (Lachmans)
• McMurrays
• No touch test
• Pivot shift

Palpation

• medial ligament
• lateral ligament
• menisci
• coronary ligament
• patella retinaculum
• patella tendon
• nerves
• joint line

PRONE LYING

Palpation

• temperature
• tenderness
• effusion
• capsule
• joint line

Neurological

• muscle power, reflexes, sensation as appropriate

Passive accessory movements

• P/A fibular
• P/A tibia

Orthopaedic tests for specific structures

• as appropriate
• Appleys

SIDE LYING

Superior tib/fib joint

Accessory movements

• Longitudinal caudad/Longitudinal cephalad (palpate joint while inverting and everting ankle)

Hip physical examination

1. STANDING

Observation

From behind:

• lower limb rotation/ position of feet
• knee creases
• gluteal fold
• PSIS
• muscle bulk
• spine
• leg length

From side:

• pelvic rotation
• lumbar spine

From in front:

• lower limb rotation
• Q angle -
• level of patellae
• quadriceps bulk
• ASIS

Functional tests and tests for other joints

• walking forwards and backwards
• flex knee to chest
• squat (may add overpressure)
• rotate trunk and pelvis while standing on one leg
• (medial and lateral rotation).
• Steps
• Hopping
• Running
• sitting to standing
• lumbar spine, combined movements.

Neurological

• muscle power, reflexes, sensation as appropriate

2. SUPINE LYING

Observation

• leg length
• lower limb rotation

Palpation

• temperature changes
• swelling and thickening

Neurological

• muscle power, reflexes, sensation as appropiate.

Active Movement

• Flexion
• Abduction / Adduction
• Lateral rotation / Medial rotation (in neutral and /or 90º flexion)

Resisted or static tests

• Flexion (performed in neurological test).
• Abduction /Adduction
• Lateral rotation/medical rotation (in 90ºflexion)

Muscle function

• Iliopsoas, quadriceps, tensor fascia lata, hamstrings
• Adductor length and differentiation.

Tests for other regions and structure

• sacroiliac joints
• knee

Passive movements: Passive physiological movements

• Flexion
• Abduction
• Lateral rotation /Medial rotation (in neutral and 90º flexion)

Combined physiological movements

• Flexion – Adduction
• (special test performed from 90-140º flexion)
• Flexion – Abduction – External rotation

Passive accessory Movements

• Longitudinal distraction in extension
• Longitudinal distraction in 90º flexion
• Lateral distraction in 90º flexion (may be performed in any combined position)

3. SIDE LYING: Passive Accessory Movements

• Longitudinal caudad
• PA and AP on greater trocanter

4. PRONE LYING

Neurological

• Muscle power, reflexes, sensation as appropriate.

Active movements.

• Extension
• Medial rotation/ Lateral rotation

Passive movements: Passive physiological movements

• Extension
• Medial rotation/ Lateral rotation

Tests for other regions and structures

• lumbar spine
• sacroiliac joints

Palpation

• Piriformis
• Bursae

Muscles function

• Hip extension  “firing “ pattern

Shoulder Examination

Format:

1. Initial impression
2. Inspection
3. Range of movement
4. Muscle strength tests
5. Stability assessment
6. Special tests
7. Palpation
8. Neurological assessment
9. Sports specific function

1.  Initial impression:

• general body condition
• systemic disease
• antalgic posture
• willingness to move
• level of distress

2.  Inspection:

• asymmetry
• swelling
• scapular position
• glenohumeral position
• orientation of dependent arm
• muscle wasting
• deformities

3.  Range of Movement

• examine in upright and supine with overpressure EOR as applicable.
• Look for quality & potential compensations

• Total elevation
• Abduction + / – differentiation
• External rotation
  • dependant
  • 90 º abduction
• Internal rotation (hand behind back)
• Horizontal flexion

4.  Muscle strength testing: (stand & supine)

• specific muscle weakness / neurological deficit ?
• strength through range.

Scapular control on thorax:

• Trapezius
• Serratus Anterior

Humeral control in glenoid:

• External rotation
• Internal rotation

5.  Stability assessment: may be unidirectional or multidirectional

• GH translation (drawer) test
  • uni or multidirectional
  • instability
• Sulcus test – inferior instability
• Apprehension (crank) test – anterior instability
• Relocation test – anterior instability.
• Jerk test – posterior instability
• Push – pull test – posterior instability

6.  Special tests:

• Impingements
  • multifactorial etiology, structures potentially involved – rotator cuff,
  • Long head of Biceps, sub-acromial bursa, plexus.
• Tests (specificity imprecise):
  • flexion (EOR)
  • Flexion / internal rotation
  • Speed’s test (LHB impingement)
  • Ludlington’s test (LHB impingement)
  • Abduction
  • Dynamic impingement test (Allingham’s test)
  • Impingement test with local steroid
• Neurodynamic test (ULTT1)
• Cervical screening:
  • physiological with overpressure
  • Combined movements

7.  Palpation:

• Rotator cuff, LHB, A/C joint, muscle tone.
• Accessory joint movement – 3 key movements
• Quadrant & locking positions

8.  Neurological:

• Reflexes.
  • C5 – Deltoid
  • C5&6 – Biceps
  • C6 – Brachioradalis
  • C7 – Triceps
  • C8 – Pronator Quadratus
• Power.
  • C1&2 – Occipital flexion /extension
  • C2&3 – Cervical flexion / extension
  • C3&4 -  Shoulder girdle elevation
  • C5      -  Shoulder abduction
  • C5&6 -  Elbow flexion
  • C6      -  Wrist extension / rad. Dev.
  • C7      -  Elbow extension
  • C8      -  Thumb distal phalanx extension
  • T1       -  Fifth finger abduction

9.  Sports specific function:

• Serving action
• Swimming action
• Throwing
• Lifting

Shoulder Impingement References

Some folks have asked for a list of references.

Click here to download

Shoulder Impingement slides

As promised here is the link to the accompanying slide presentation from last week’s audio download

www.physiodigest.com/presentations/slides/player.html

Instructions for use:

1 Double click on link

2 Slides will play automatically

3. Pause, forward, rewind from the control panel at the bottom of the player screen.

4, Can skip to slides from the left hand side slide menu.

5 Suggestion - if you downloaded the audio previously you can use your MP3 player whilst viewing the slideshow.

Hope you enjoy

David

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