Practical #2 Ortho

genu valgum

proximal tibia is angle toward midline more than 5° relative to femur

genu varum

proximal tibia is angle away midline more than 5° relative to femur

genu recurvatum

tibiofemoral extension greater than 0°

vastus intermedius

o: anterior surface of shaft of femur

ins: tibial tuberosity, via patella, and patellar ligament

a: knee extension

inn: femoral (L2, L3, L4)

vastus medialis

o: medial lip of lines aspera of femur

ins: tibial tuberosity, via patella, and patellar ligament

a: knee extension

inn: femoral (L2, L3, L4)

rectus femoris

o: anterior inferior iliac spine and just above acetabulum of os coxae

ins: tibial tuberosity, via patella, and patellar ligament

a: knee extension

inn: femoral (L2, L3, L4)

vastus lateralis

o: greater trochanter and lateral lip of linea aspera of femur

ins: tibial tuberosity, via patella, and patellar ligament

a: knee extension

inn: femoral (L2, L3, L4)

sartorius

o: anterior superior iliac spine

ins: proximal medial surface of tibia, below tuberosity

a: knee flexion and internal rotation

inn: femoral (L2, L3, L4)

gracilis

o: inferior ramus of pubis

ins: medial surface of tibia

a: knee flexion and internal rotation

inn: obturator (L3, L4)

semitendinosus

o: ischial tubersoity

ins: medial surface of proximal end of tibia

a: knee flexion and internal rotation

inn: tibial (S1, S2)

popliteus

o: lateral condyle of femur

ins: posterior surface of tibia below tibial plateau

a: knee flexion and internal rotation

inn: tibial (L4, L5, S1)

biceps femoris

o: long head - ischial tuberosity, short head - lateral lip of linea aspera

ins: lateral surface of head of fibula and lateral condyle of tibia

a: knee flexion and external rotation

inn: sciatic (L5, S1, S2)

semimembranosus

o: ischial tuberosity

ins: medial surface of proximal end of tibia

a: knee flexion and internal rotation

inn: tibial (S1, S2)

gastrocnemius

o: lateral head - posterior lateral condyle of femur, medial head - popliteal surface of femur above medial condyle

ins: posterior surface of calcaneus

a: knee flexion

inn: tibial (S1, S2)

patella

tibial tuberosity

medial joint line

medial tibial plateau

medial femoral condyle

medial femoral epicondyle

lateral joint line

fibular head

gerdy’s tubercle

lateral femoral condyle

lateral femoral epicondyle

ischial tuberosity

patellar tendon

quadriceps tendon

pes anserine tendon

medial meniscus

pes anserine bursa

medial collateral ligament (MCL)

lateral collateral ligament (LCL)

iliotibial band

popliteal fossa

popliteal artery

girth measurements

positive test: difference of ±1 cm compared bilaterally

implications: increased girth on injured side across joint line - edema, decreased muscular girth on injured side - atrophy

sweep test

positive test: reformation of edema on medial side of knee when pressure is applied to lateral aspect

implications: swelling within joint capsule indicating possible ACL trauma, osteochondral fracture, synovitis, meniscal lesion or patellar dislocation

ballotable patella

positive test: patella depresses and strikes patellar groove (femoral trochlea) and returns back to its former position

implications: effusion within joint capsule

anterior drawer test

positive test: increased amount of anterior tibial translation compared w/ opposite (uninvolved) limb or lack of firm endpoint

implications: ACL sprain

lachman test

positive test: increased amount of anterior tibial translation

implications: ACL sprain

prone lachman

positive test: excessive anterior translation relative to uninvolved knee indicates ACL sprain

implications: positive test results for anterior drawer and/ or lachman test and in alternate lachman test indicate ACL sprain, positive anterior drawer test and/ or lachman test result and negative alternate lachman test result implicate PCL sprain

posterior drawer test

positive test: increased amount of posterior tibial translation compared w/ opposite (uninvolved) limb or lack of firm endpoint

implications: PCL sprain

godfrey’s test

positive test: unilateral posterior (downward) displacement of tibial tuberosity

implications: PCL sprain

valgus stress test

positive test: increased laxity, decreased quality of endpoint, and/ or pain compared w/ uninvolved limb

implications: in complete extension - MCL sprain, medial joint capsule, and cruciate ligaments; distal femoral epiphyseal fracture, in 25° flexion - MCL sprain

varus stress test

positive test: increased laxity, decreased quality of endpoint, and/ or pain compared w/ uninvolved limb

implications: in complete extension - LCL sprain, lateral joint capsule, and cruciate ligaments, and related structures indicating possible rotational instability of joint; distal femoral epiphyseal fracture, in 25° flexion - LCL sprain

lever sign

positive test: heel remains flat on table

implications: ACL rupture

quadriceps active test

positive test: anterior translation of tibia on femur

implications: grade II or III PCL sprain

slocum drawer test

positive test: increased amount of anterior tibial translation compared w/ opposite (uninvolved) limb or lack of firm endpoint

implications: test for anterolateral instability - damage to ACL, anterolateral capsule, LCL, IT band, popliteus tendon, posterolateral complex, test for anteromedial instability - damage to MCL, anteromedial capsule, ACL, posteromedial capsule, pes anserine

crossover test

positive test: patient reports pain, instability, or apprehension

implications: ALRI - instability of lateral capsular restraints, AMRI - instability of medial capsular restraints

pivot shift test/jerk test

positive test: tibia’s position on femur reduces as leg is flexed in range of 30°-40°, jerk test - during extension, anterior reduction is felt in same range

implications: ACL anterolateral capsule, LCL biceps femoris, popliteus, posterolateral capsule

slocum ALRI test

positive test: appreciable “clunk” or instability as lateral tibial plateau sublimates or pain or instability is reported

implications: tear of ACL, LCL, anterolateral capsule, arcuate ligament complex, biceps femoris, tendon, and/ or IT band

flexion-rotation drawer test

positive test: femur is reducing itself on tibia by moving anteriorly and internally, rotating on tibia

implications: tears of ACL, LCL, anterolateral capsule, arcuate ligament complex, biceps femoris tendon

external rotation test (dial test)

positive test: increase of external rotation greater than 10° compared w/ opposite side

implications: difference at 30° of knee flexion but not at 90° - injury isolated to posterolateral corner of knee, difference at 30° and 90° of knee flexion - trauma to PCL, posterolateral knee structures, and posterolateral corner, difference at 90° of knee flexion but not at 30° - isolated PCL sprain

external rotation recurvatum test

positive test: marked difference in hyperextension, external femoral rotation, and varus alignment between two knees

implications: posterolateral corner trauma, ACL sprain, and posterolateral rotary instability

posterolateral/posteromedial drawer test

positive test: increased external rotation of lateral (posterolateral) or medial (posteromedial) tibial condyle relative to uninvolved side

implications: posterolateral test - tibia externally rotated 15°, trauma to posterolateral corner and PCL, possible posterolateral rotational instability, posteromedial test - tibia internally rotated 15°, PCL tear, oblique ligament, MCL, posteromedial capsule, semimebranosus

reverse pivot shift test

positive test: appreciate reduction (“clunk”) of tibia on femur

implications: posterolateral rotational instability and/ or trauma to posterolateral corner

dynamic posterior shift test

positive test: “clunk” or “jerk” as knee nears full extension, representing subluxated tibia reducing on femur

implications: posterolateral instability

mcmurray test

positive test: popping, clicking, or locking of knee; pain emanating from menisci; or sensation similar to that experienced during ambulation

implications: meniscal tear on side of reported symptoms

apley compression and distraction tests

positive test: pain experienced during compression that is reduced or eliminated during distraction

implications: meniscal tear

thessaly test

positive test: joint-line discomfort, complaints of “locking” or “catching”

implications: lesion of medial or lateral meniscus, depending on source of pain and/or catching sensation

wilson’s test

positive test: pain experienced during extension w/ internal tibial rotation that is relieved by externally rotating tibia

implications: OCD or osteochondritis dissecans on intercondylar area of medial femoral condyle

noble compression test

positive test: pain under thumb, most commonly as knee approaches 30°

implications: inflammation of IT band or it associated bursa or inflammation of lateral femoral condyle

proximal tibiofibular syndesmosis

positive test: hyper or hypomobility of fibula on tibia compared w/ uninvolved side and/ or pain elicited during test

implications: anterior fibular shift indicates damage to proximal posterior tibiofibular ligament; posterior displacement reflects instability of anterior tibiofibular ligament of proximal tibiofibular syndesmosis, hypomobility may alter proximal and distal joint mechanics

step length

distance traveled between initial contacts of right and left foot

step width

distance between points of contact of both feet

stride length

linear distance covered in one stride

foot angle

angle of foot (imaginary line from heel to second toe) relative to line of progression

stance time

amount of time spent in contact w/ surface by single limb

pelvic drop

hip drop that occurs when opposite limb is wb could be result of either leg-length discrepancy (shorter side shows dropped hip) or weak-gluteus medius muscle causing short-leg or tredenelenburg gait

asymmetrical arm swing

arm swing occurs primarily to counterbalance activity of hips and pelvis during walking and running

gluteus maximus gait

at initial contact, thorax is posteriorly to maintain hip extension during stance phase often causing lurching of trunk (cause: weakness or paralysis of gluteus maximus muscle)

stiff knee or hip gait

in swing phase, affected extremity is lifted higher than normal to compensate for knee or hip stiffness, to accomplish this uninvolved extremity demonstrates increased plantar flexion (cause: knee pathologies such as meniscal or ligamentous tears or hip pathologies such as bursitis or muscle tears that result in decreased ROM

trendelenburg gait

during stance phase of affected limb, thorax lists toward involved limb, this serves to maintain COM and prevent drop in pelvis on affected side (cause: weakness of gluteus medius muscle)

calcaneal gait

during stance phase, increased dorsiflexion and knee flexion occur on affected side resulting in decreased step length (cause: paralysis or weakness of plantar flexors or pain when wb on forefoot or toes caused by such conditions as blisters, hallux rigid, sesamoiditis, or ankle sprains)

psoatic limp

to compensate during swing phase, lateral rotation and flexion of trunk occurs w/ hip adduction, trunk and pelvic movement are exaggerated (cause: weakness or reflex inhibition of psoas major muscle)

short leg gait

increased pronation occurs in subtalar joint of long leg, accompanied by shift of trunk toward longer extremity (cause: true leg-length discrepancy; right leg is longer)

steppage gait

foot slaps as initial contact owing to drop foot, during swing face unaffected limb demonstrates increased hip and knee flexion to avoid toe dragging, producing “high-step” pattern (cause: weakness or paralysis of dorsiflexors)

abductory twist gait

foot abruptly abducts beginning at heel-off and then rotates into adduction through swing; it’s often seen w/ excessive pronation (cause: weak hip external rotators and abductors; contracture at 1st MTP joint)