Osteopathic diagnosis of the knee joint
So we are gonna follow our
mantra of look-feel-move.
So we're gonna start with
observation of both knees
taking a look to see if there's
any asymmetries, any swelling,
anything that we could note
that is out of the ordinary.
And so through observation,
sometimes we might see more swelling,
maybe some redness from infection you also
wanna take note of the muscle masses here.
Sometimes, the vastus medialis might
be a little bit smaller and wasting
and contributing to knee pain
causing patellar track issues
So take a look at the knees,
see if you see anything closely abnormal
that may contribute
to knee complaints.
After observation, we're going to palpate
and feel the structures of the knee
So you wanna get the tone of the quadricep to
see if there's any spasms or decrease in tone
You wanna feel the patella, check for any
swelling in the region, any point tenderness.
You want to feel around the
patella and then below the patella,
you could get a sense of the patellar tendon
as it blends into the tibial tuberosity
at the tibial tuberosity,
sometimes patients may have pain.
Also, just a little bit medial to it you could
find pes anserine which is the attachment of
set of 3 muscles and that could also
cause issues and problems in that point.
You want to get a sense of the posterior
knee and check the popliteal fosssa,
get your hands behind the
knee, assess the tension,
sometimes you may have baker's
cyst or swelling behind the knee
and then check around the fibular head,
sometimes there might be tenderness
and points around the knee
that might cause problems.
Your IT band or your Iliotibial band comes
down and blends into that fibular head
So, tension over here is very common with
overuse, with runners causing lateral knee pain
So assessing the tissue in the musculoskeletal
structures around the knee is important using palpation
Once we observed and palpated it, we're
going to motion test the knee,
the knee's primary motion is in the
saggital plane with flexion and extension
So the knee at 0 is straight and
when I'm checking for flexion,
what I'm going to do is to bend the knee
and see how far the knee could bend.
And then you wanna assess the range of
motion on both sides and compare the sides
in addition to seeing how
far the knee could flex.
Now extension is similar to the elbow where it
locks out and it really doesn't hyperextend.
If you see a knee hyperextending too much,
then that may be a cause of concern.
There's some small motions in the
coronal plane with AB/ADduction,
so if abduction bringing the
distal leg out in a valgus motion
Again, very little play in there, the anatomy of
the knee does not allow for too much valgus motion
and then varus would be bringing the
distal leg a little bit more medially
and that would be a varus motion
or medial ADduction of the knee
There is also very little internal and
external rotation of the knee again,
because of the way the anatomy does not allow
for a lot of play in the transverse plane here so,
you could do a little bit of internal rotation and
external but is very limited at the knee joint.
So the primary motion is flexion and extension and
we could diagnose somatic dysfunctions of the knee
based on how much flexion
and extension occurs.
If you find a restriction of the knee, then
potentially there might be a somatic dysfunction.
So if I was to flex the knee and really only get
to 90 degrees and notice a restriction in flexion,
then we'd call that an
extension somatic dysfunction.
So with knee motion testing, if we
find that the knee can freely flex,
but cannot fully extend, then that
is a flexion somatic dysfunction.
So to diagnose the fibular head,
remember the fibula is a long bone
and you have the fibular head here,
as you come down from the joint space,
you could find the fibular head, it should be a knob
here and that is the proximal portion of the fibula.
The distal portion is
your lateral malleoli.
So there's a relationship when you move your
ankle, it will create motion at the fibular head
and so we have somatic
dysfunctions that could occur here,
what we wanna do is we wanna
monitor the fibular head
and we could motion test
by moving the ankles.
So when I dorsiflex and evert the foot, the
fibular head should move anterior into my thumb.
when I plantarflex and invert, the fibular
head will then move posteriorly into my fingers
and so I could assess the range
of motion here at the fibular head
as I move the ankle into dorsiflexion,
eversion or plantarflexion and eversion.
You name the fibular head for
the side that it likes to go to.
So if the fibular head likes to glide
posteriorly, that's a posterior fibular head.
If it likes to glide anteriorly,
that's an anterior fibular head.
The other way you could diagnose a fibular
head is to directly motion test this.
So you could get on the
fibula and on the fibular head
and you're going to try to articulate the
joint by pushing posterior and anterior.
But you don't wanna pull straight in a sagittal plane
because of the articulation of the fibula on the tibia
it's a little bit more angled, so what you're
gonna do is you're gonna push more posteriorly
and medially and pull
more anterior and lateral.
This way you could be more accurate when
you're trying to mobilize the fibular head.
It doesn't move that much but you would usually find a
freedom of motion either on one plane or the other.
And so, you will name it for
the way that it likes to glide.
Does it like to glide anterior,
then that will be a anterior fibular head
and if it likes to glide posterior,
then that's a posterior fibular head.
There are several special tests
that we could perform on the knee
to help rule out or rule in different
pathologies with the knee.
So first we're gonna take
a look at the knee cap.
So the knee cap, sometimes could be irritated,
you could have swelling behind it.
And so, you could have a special
test called the ballotement test.
and what the ballotment test does
is if there is swelling in the knee,
you're gonna gently push down on
the knee cap and as you push down
because of all the fluid,
it kind of pops up and down.
So, if there is swelling behind the knee and you're
suspecting that there is fluid behind the knee,
you could take the knee cap and just gently
push down and you'll get a sense of the knee,
kind of floating in water,
pushing down and coming back up.
So the patellar grind test is a test that we could use
to try to assess for patellofemoral tracking syndrome
So your patella rise on the femur on a track
and if there is damage to the cartilage,
wear and tear or if the patella is not tracking
well because of the pull from the quadricep,
it could cause inflammation behind the knee.
So, the patellar grind test is you're
gonna take a patella
and just kind of push it inferiorly
towards the ankle and the foot
and we're gonna ask the patient to
contract their quadricep muscle,
so go ahead tighten up your
quadricep muscle and relax.
And when they tighten up that quadricep
muscle, if you're having pain,
that would be a positive test because there's
inflammation there and as they try to pull,
you could elicit pain.
So a positive patellar grind test would mean
that there's a need for more investigation
to rule out patellofemoral
So there's ligaments that
help to stabilize our knee.
We have the anterior cruciate ligament
and the posterior cruciate ligament
and after some sort of trauma, there may
be compromised tears to those ligaments
and there's special test to try
to see if the ligaments are torn.
So the anterior cruciate ligaments prevents
anterior slippage of the tibia on the femur.
So to motion test to see if it's intact,
we could perform an anterior draw test.
So the anterior draw test,
we're going to flex the knee up,
we could stabilize the foot by kind of sitting
on it, and then we're gonna place our hands
behind the tibia and try to anteriorly
draw the tibia on the femur.
And so if there's increased play if the joint moves
forward excessively, if there's no good end feel,
then there's a possibility that the
anterior cruciate ligament has been torn.
If you wanted to check this, you
could also do a Lachman's test.
So the Lachman's test test for anterior cruciate
ligament stability but this is done at 30 degree angle
and what you're going to do is
you're going to stabilize the femur
while you're simultaneously
pulling up on the tibia.
So it's still motion testing the
motion of the tibia on the femur
by drawing the tibia anteriorly and
here, if you have increased joint play,
not a good end feel as you're
pulling, then that's a positive test
and you have to suspect possible
anterior cruciate ligament damage.
To test for the integrity of the posterior cruciate
ligament, what we're gonna do is to try to
push the tibia posteriorly on the femur, so the
posterior cruciate ligament will prevent the tibia
from gliding posteriorly on the
femur, so what we're going to do is to
bring the leg up to 90 degrees, support the
feet by sitting on the foot here a little bit.
I'm gonna get my palms anteriorly on
the tibia and then push into the table,
as I push into the table,
if there's increased give,
then that might be a possibility of
a posterior cruciate ligament tear.
So the knee also has a medial collateral
ligament and a lateral collateral ligament
to help stabilize the knee from
lateral motions and medial motions.
And so, if we wanna test the medial collateral ligament,
what we're going to do is we're going to gap that area
so we're going to create a
valgus stress on the knee.
So I'm gonna support the femur and I'm gonna
keep the knee bent at like 30 degrees.
If you keep it full, fully locked out at
0 degress, it's not gonna have any give
for you to create a
valgus or varus stress.
So in valgus stress, I'm taking the
distal portion of the leg laterally,
and so as I do that, it gaps the medial aspect, testing
for the integrity of the medial collateral ligament.
If there's increased motion and movement or if there's
pain there, then I need to suspect
possible injury or tear of the
medial collateral ligament
For the lateral collateral ligament, what I'm
going to do is perform a varus stress test
So the varus stress test, we're going to be taking
the distal leg and bringing it more medially.
and as I bring it, bring the lower leg medially,
that's going to gap the outer portion of the knee
thus, if there's increased motion or pain on the lateral
aspect of the knee as I perform a varus stress test,
then that is a positive test for a potential
lateral collateral ligament injury.
So the meniscus helps to buffer the
space between the femur and the tibia.
So we have a medial and lateral meniscus that
are gel pads that lie between the bones.
Sometimes, those menisci could be injured
due to trauma or due to wear and tear.
So, to try to check if there is a meniscal
injury, we could perform McMurray's test.
So McMurray's test puts a strain on the knee
that would compress the tibia on the femur.
So when we fully flex the knee,
that would compress that region,
so, we're gonna start by supporting
the leg, I'm gonna flex the knee up.
I'm gonna monitor at the joint
spaces where the meniscus would lie
cause sometimes I could detect
the click or popping noise.
We're going to support the
calcaneous here so we could create
internal or external
rotation force at the knee.
So what I'm gonna start with is I'm
going to internally rotate the knee,
I'm going to flex the knee all the way
up and I'm going to ADduct the knee
So flexion, ADduction, internal rotation, holding
that, I'm gonna slowly straighten up the knee
and as I straighten out the knee, sometimes you'll
feel a pop or a click or the patient may have pain
indicating a meniscal injury and
then we're gonna test the other side
by externally rotating,
ABducting and fully flexing the knee.
And then from here,
we're gonna slowly straighten out the leg
and then sometimes you
could feel a click.
So again, when you do it combined
more smoothly you could do
internal rotation, ADduction,
straightening out the knee
and then external rotation,
ABduction and straigthening out the knee.
The key really is to see if there's any pain
or if any clicks occur and if that does,
that's a positive McMurray test
indicating a meniscal injury or tear.
Apley's compression test.
So Apley's compression test is used to
assess for any sort of meniscus injury.
So what we're going to do is
we're going to flex the knee up,
and provide a compression
force down to the table.
And when while we're compressing, we're going
to add external rotation and internal rotation.
This will put a strain on the
meniscus and if there's inflammation
or some sort of meniscal tear or
damage, that's gonna elicit pain.
So, we're gonna flex up to 90 degrees,
we're gonna stabilize the foot,
add a compression down towards the table and
then internally rotate and externally rotate.
and we'll see if the
patient has pain.
Again, if there's pain present depending
on which side the patient feels the pain,
there might be a medial
or lateral meniscal injury.
Apley's distraction test.
So Apley's distraction test is a test
where we're going to be flexing the knee
with the patient in prone position
and we're going to be pulling,
and as we pull the lower leg, up towards the
ceiling, we're gonna be stressing the ligaments.
So this could be done in conjunction
with the Apley's compression test
cause after you compress, then you
could do the second part and traction.
And if we traction and internally and
externally rotate and the patient has pain,
that could give us a better idea of whether
or not there is ligamentous injury there.
So, we're gonna flex the knee up to 90
degrees, stabilize by the hamstrings,
keeping the knee supported on to the table, and then
we're gonna provide a force towards the ceiling,
tractioning on those ligaments
and then we're gonna provide
a little bit of internal rotation to
the knee and external rotation to the knee
and if there's any pain with internal
rotation or external rotation,
then that's a positive Apley's distraction
test for some sort of ligamentous injury.