module 4

Special Maneuvers in Hip and Knee Examination

Hip Examination Techniques

  • General Considerations

    • The examiner must assess the patient's ability to move their hip.

    • Meta-analysis indicates no single test effectively discriminates specific hip pathologies.

Testing for Groin Strain

  • Indications: When a groin strain is suspected due to sudden forced abduction of the hip.

  • Maneuvers:

    • FOBER Test (Flexion, Abduction, External Rotation)

    • Test for pain: Patient supine, leg positioned at 90 degrees of flexion, externally rotate and abduct.

    • Positive Test: Pain elicited with resisted adduction, indicating possible pathology of the hip or sacroiliac joint.

Testing for Hip Flexion

  • Kendall Test:

    • Patient Position: Sitting with thigh halfway off the examining table.

    • Procedure: Patient lies down and flexes the opposite leg toward the chest.

    • Normal Findings: Posterior thigh touches the table, knee passes reflexively.

    • Interpretation:

    • Flexion deformity presence: Affected hip rises off the table; indicates limited extension.

    • Leg extends beyond 90 degrees: Suggests rectus femoris shortening.

    • Extended leg flexes to 90 degrees or more: Indicates iliopsoas tightness.

Knee Joint Anatomy

  • General Description: The knee is the largest joint, a hinge joint formed by:

    • Bones Involved: Femur, tibia, patella.

    • Articular Surfaces: 3 total; 2 between femur and tibia, 1 between femur and patella.

    • Stability Considerations: Lacks inherent stability; relies on ligaments and tendons.

Bony Landmarks in and around the Knee

  • Medial Surface: Identify:

    • Adductor tubercle

    • Medial epicondyle of the femur

    • Medial condyle of the tibia

  • Anterior Surface: Identify:

    • Patella rests on the anterior surface of the femur, embedded in the quadriceps tendon, which continues as the patellar tendon inserting at the tibial tuberosity.

  • Lateral Surface: Identify:

    • Lateral epicondyle of the femur

    • Lateral condyle of the tibia

    • Head of the fibula.

Menisci and Ligaments of the Knee

  • Menisci: Medial and lateral meniscus acts as shock absorbers, cushioning action between femur and tibia.

  • Ligaments:

    • Medial Collateral Ligament (MCL): Attaches from medial femoral epicondyle to medial condyle at the tibia; also connects with medial meniscus.

    • Lateral Collateral Ligament (LCL): Connects lateral femoral epicondyle and head of fibula, provides lateral stability.

    • Anterior Cruciate Ligament (ACL): Prevents tibia from sliding forward on the femur; crosses from anterior medial tibia to lateral femoral condyle.

    • Posterior Cruciate Ligament (PCL): Prevents tibia from slipping backward on the femur; extends from posterior tibia to medial femoral condyle.

Techniques of Examination for the Knee Joint

  • Inspection:

    • Observe gait, knee flexion during ambulation, alignment, contour, and presence of swelling.

    • Check for quadriceps atrophy, bruising, and hollows around the patella.

  • Palpation:

    • Assess tenderness in various parts:

    • Tibiofemoral joint: medial/lateral compartments, patellofemoral compartment, knee ligaments.

Special Maneuvers for Knee Examination

  • McMurray Test: Assesses meniscal tears; positive if palpable click or pop felt at the joint line.

  • Valgus (MCL)/ Varus (LCL) Stress Tests: Check stability of the respective ligaments.

  • Anterior Drawer Sign & Lachman Test: Tests integrity of the ACL.

  • Posterior Drawer Sign: Tests integrity of the PCL.

  • Effusion Tests: Bulge sign, balloon sign, and ballotting the patella used for checking fluid in the joint.

Ankle and Foot Anatomy

  • Overview: The ankle and foot bear body weight and absorb impact, serving crucial functions.

  • Joint Description: Hinge joint formed by tibia, fibula, and talus; subtalar talocrural joint involved.

Major Ligaments of Ankle

  • Medial: Deltoid ligament, protecting against eversion stress.

  • Lateral: Anterior talofibular, calcaneofibular, and posterior talofibular ligaments, more susceptible to injury from inversion.

Techniques of Examination for Ankle and Foot

  • Inspection: Evaluate for deformities, nodules, swelling, calluses.

  • Palpation: Anterior aspect of the ankle, Achilles tendon, and metatarsophalangeal joints.

  • Range of Motion Assessment:

    • Dorsiflexion, plantar flexion, inversion, and eversion with instructions for patients.

Special Maneuvers for Ankle Integrity

  • Talar Tilt Test: Tests stability by inverting and everting the foot to check for laxity.

  • Achilles Tendon Test: Squeeze calf and watch for plantar flexion; absent movement indicates rupture.

Health Promotion and Counseling Recommendations

  • Key Topics: Low back pain management, osteoporosis prevention, fall injuries.

  • Recommendations Include:

    • Staying active and engaging in proper nutrition.

    • Understanding vulnerabilities of joints (trauma risk), and encouraging independent disease management to preserve mobility and function.

  • Low Back Pain:

    • Prevalence - Over 80% lifetime occurrence; manage with a mix of pharmacologic and non-pharmacologic therapies.

  • Osteoporosis:

    • Defined by decreased bone density; increased fracture risk in aging populations, especially postmenopausal women.

  • Screening: Recommended for women over 65 and men 70 and older based on risk factors.