__Measurement_of_Joint_Motion__A_Guide_to_Goniometry_3rd_Edition

194 PA RTill LOWER-EXTREMITY TESTING FLEXION in the hamstring muscles. Maintain the extremity in Motion occurs in the sagittal plane around a mcdial w ncutral roration and abduction and adduction throughw lateral axis. The mean hip flexion ROM for adults is 100 degrees according to the AMA ., and 121 degrees accord- out the motion (Fig. 8-11). The end of the ROM occurs ing to the study by Roach and Miles. 7 Sec Tables 8-1, when resistance to further motion is fclt and attempts at 8-2, a~d 8-5 for additional ROM information. overcoming the resistance cause posterior tilting of the pelvis_ Testing Position Normal End-feel Place the subject in the supine position, with rhe knees extended and both hips in 0 degrees of abduction, adduc- The end-feci is usually soft because of contact between tion, and roration. the muscle bulk of the anterior thigh and the lowet abdomen. However, the end-feel may be firm because of Stabilization tension in the posterior joint capsule and the gluteus maximus muscle. Stabilize the pelvis with one hand (0 prevent posterior tilting or rotation. Keep the contralarcrallower extremity Goniometer Alignment flat on the table in the neutral position to provide addi- tional stabilization. Sec Figures 8-12 and 8-13. Testing Motion L Cemer the fulcrum of the goniometer over the lateral aspect of the hip joint, using the greatcr Flex the hip by lifting the thigh off the table. Allow the knee to flex passively during the motion ro lessen tension crochanrcr of [he femur for reference. 2. Align the ptoximal arm with the lateral midline of the pelvis. 3. Align the distal arm with the lateral midline of the femur, using the lateral epicondyle as a reference. FIGURE 8-11 The cnd of hip flexion passive ROM. The pl~cement of the examiner's hnnd on the pelvis allows the examiner to stabilize the pelvis :lOci to detect any pelvic motion.

CHAPTER 8 THE HIP 195 FIGURE 8-12 Goniometer alignment in the supine starring position for measuring hip flexion ROM. FIGURE 8-13 At the cnd of the left hip flexion ROM, the examiner uses one hand to align the distal goniometer arm and [0 maintain the hip in flexion. The examiner's other hand shifts from the pelvis to hold the proximal goniometer arm aligned with the lateral midline of the subject'S pelvis. !

I! 1!oJ:..! __- , - - - - - - - - - - - - - -__--=-::-::__~ 196 PART III LOWER· EXTREMITY TESTING \"~d~ two-joint rectus femoris muscle does not limit the hip extension ROM. The end of the ROM occurs when :J~ resistance to further motion of the femur is felt and attempts at overcoming the resistance causes anterior @ ~ N1orion occurs in a sagittal plane around a medial-lateral tilting of the pelvis and/or extension of the lumbar spine. oU II axis. The mean hip extension ROM fot adults is 19 Normal End-feel 00;:..:: I~ de~z>tees accotding to Roach and Miles7 and 30 degrees The cndHfeel is firm because of tension in the anterior ,~ I accotding to the AMA:' See Tahles 8-1, 8-2, 8-4, and ....... I@ joint capsule and the iliofemoral ligament, and, to a 8-5 for additional ROM information. lesser extent, the ischiofemoral and pubofemoral liga~ Z menrs. Tension in various muscles that flex the hip, such i= B as the iliopsoas, sartorius, tensor fasciae latae, gracilis, and adductor longus, may contribute to the firm cnd- Ilil Testing Position feel. i i Place the suhject in the prone position, with hoth knees Goniometer Alignment o I extended and the hip to he tested in 0 degrees of abduc- i~= '~~I See Figures 8-15 and 8-16. tion, adduction, and rotation. A pillow may be placed under the abdomen for comfort, bur no pillow should be 1. Center the fulcrum of the goniometer over the lateral aspect of the hip joint, using the greater u. I placed under the head. trochanter of the femur for reference. a ~'Ii 2. Align the proximal arm with the lateral midline of the pelvis. Iu.l Stabilization I~ Hold the pelvis with one hand to prevent an anterior tilt. 3. Align the distal arm with the lateral midline of the I~ I Keep the contralateral extremity flat on the table to femur, using the lateral epicondyle as a reference. provide additional pelvic stabilization I, Testing Motion I Extend the hip by raising the lower extremity from the I table (Figure 8--14). Mainrain rhe knee in extension I throughout the movement to ensure that tension in the I ) FIGURE 8-14 The subject's right lower extremity ;It the end of hip extension ROM. The examiner lIses one hand to support the distal femur and maintain the hip in extension while her other hand grasps the pelvis at the level of the anterior superior iliac spine. Because the examiner's hand is on the subject's pelvis l the examiner is able to detect p{.·lvic tilting.

CHAPTER 8 THE HIP 197 ! ( I ,.·. ·· / I·· FIGURE 8-15 Goniometer :t1ignrncru in the prone st:lrring position for measuring hip cxtt:llsion ROM. / FIGURE 8-16 At lIle ('nd of hip cxrcnsion ROM, rhe examiner uses one hand to hold dle proxima! goniometer arm in alit;nmcl1t. The cx;unincr's other hand supports che subjccc\"s femur <lnd keeps rhe distal goniometer arm in ;llignmcnt. ---~---~-'--'-'----

~ I 1ci:.s .j- - ------ ---- - ------ - --- -- PAR T I I I LOW E 198 R· EXT REM I T Y T EST ING Vii furrher motioll of the femur i~ (dr ~llld <![[ClllprS wover. come tht n.:sislall\"':c causes brcr:ll pelvic rilring, pelVic :d~ ~ ABDUCTION roration, or lateral flexion of rh(: trunk. o IOwu?i.J~ Motion occurs in the frontal plane around an anterior- Normal End·feel posterior axis. The mean ROM in abduction is 40 The end-fed i~ firlll hecause: of tension in tht' inferior 110~ • degrees according to the AMA4 and 42 degrees according (medial) joint <'::lpsulc, pubofemoral lig:'lmer1t, ischiofcmor~'ll liganlt:nr, and inferior band of the ~ Roach and Miles.' (Sec Tables 8-1, 8-2, and 8-5 for iliofemor:ll liganH.:nr. Passive tension in rhe addUCtor magnus, adduuor longus, addw,,::ror brevis, pl.:...:tincus, ~;j ;~::~n~:~l~~::~~Z \" additional ROM information.) and gracilis muscles m:1Y contributt to the firm end-fecI. in the supine position, with the knees 0'] extended and the hips in 0 degrees of flexion, extension, Goniometer Alignment ~Ip R and [oration. Sec Figures S-l S :llld g-19. Stabilization 1. (\\:nrcr the fulcrum of rhL' goniOllll'tcf over rhe anre- 01!. u.. 11 rior superior iliac Spill(' (ASIS) of the c;..;trcmiry Keep 0 hand on the pelvis to prevent latero' tilting ond bl-ing measured. QiwN rotation. Watch the trunk fOf lateral [funk flexion. o 2. Align rhe prnxim;ll ;1rtll with ;11l im:lginary hori- Testing Motion zOlltal lint.\" t:;..;rcnding from olle ASIS to rht.' other. , ~Il, Abduct the hip by sliding the lower extremity laterally 3. Align the distal arm with the ,\\Iw:rior fIlidlilll: of the j:i ftlllllf. lIsing the Illidlinc:: of tht: p;Hclia tor flJcrcncc. o (Fig. 8-17). Do nor allow laterol rototion or flexion of i\"If; -' ! the hip. The end of the ROM occurs when resistance to i '1 .~ ····1 I fi FIGURE 8-17 \"file Idt lnwl'r l'xrremitv ,It rll(· end of rh(' hip ~lbdlh.:rion ItO:,,1. The l.:x:uuincr\" ·lISl'S Olll' h:md to pull the Sllbjl\"ct's kg into ahdlh.:rinll. (Thl\" l·x,lInincr\"s ~rip Oil dll~ :wkli: is dl.:si~nl\"d w pn.·\\·l\"IH I:w:r:tl roracion of till' hip.) The examiner's othl'r h:llld nor only sr:lbi- li/.es dll\" pdvis bue also i~ lIsed ro dl'tl.'t:! pl\"lvi<.: motion.

CHAPTER 8 THE HIP 199 us, el. ' Itc- my :>ci- ICC. FIGURE 8-18 In the starting position for measuring hip abduction ROM, rhe goniometer is at 90 degrees. This position is considered to be the O-degree starring position. Therefore, rhe examiner must transpose her reading from 90 degrees to 0 degrees. For example, an actual reading of 90-120 degrees on the goniometer is recorded as 0·30 degrees. d of Irtnd nt:r's .lIOIl t:lbi- :ioJl. FIGURE 8-19 Goniometcr alignment ar rhc end of the abduction ROM. The cxaminer has determined the end-feci and Ius moved her right hand from stabilizing the pelvis in order to hold rhe goniometer in corrcer alignment.

200 PA RTill LOWER·EXTREMITY TESTING ADDUCTION 5tabilization Motion occurs in a frontal plane around an anrcrior- Sr:lhilizc rhe pelvis to prevcnr lan:r,ll rilring. posterior axis. The mean ROM in adduction for adults is 20 degrees according to the AMA4 and 30 degrees Testing Motion according to the AAOS.J See Tables 8-1, 8-2, and 8-5 for additional ROM information. Adduct the hip by sliding (ht..:' lo\\vc:r extremity medially row~1rd the cOlllralart:r;ll lowc..:r t:xtrcmiry (Fig. 8-20).-. Testing Position Pbct: ont: h~\\[ld ;\\[ the kntc W 1110Ve rhe extremity into adduction and to lluinr;lin tht: hip in neurral flexion and Place the subject in the supine position, with both knees roration. The tnd of tht: ROr\\.'l O(('lIfS when resistance to.:' extended and the hip being tested in 0 degrees of flexion, further aJduction is ftlr and 'lrtl.'ll1prs ro OVercome the: extension, and rotation. Abduct the contralateral extrem· ity to provide sufficient space to complete the full ROM resistance: <..~;llISt· beCfal pdvic tilting, pt.:lvic.: roration, in adduction. and/or beer;,l [fllnk flexion. FIGURE 8-20 At Ill<.' end of rhe: hip addu.:rioll ROM. the examiner mainrains (h(· hip in adduction with Olll: hJ.nd and stabilizes rill: pelvis wiIh hc.:r otlH:r halld.

CHAPTER 8 THE HIP 201 'rmal End-feel Goniometer Alignment i~ See Figures 8-21 and 8-22, L Center the fulcrum of the goniometer over the \",end-feel is firm because of tension in the superior ASIS of the extremity being measured. reral) joint capsule and rhe superior band of the 2, Align the proximal arm with an imaginary hori- c~ofemoral ligament, Tension in the gluteus medius and zontal line extending from one ASIS to the other, ·'·ihinimus and [he tensor fasciae lame muscles may also 3, Align the distal arm wirh the anterior midline of the femur, using the midline of the patella for refer- ,,,,ntribute to the firm end-feeL encc. ~ URE 8-21 The alignment of the goniometer is 3t 90 FIGURE 8-22 At the end of the hip adduc<ion ROM, the examiner uses one hand [0 hold {he goniometer body over the &&rees. Therefore. when the examiner records the measure· subject's anterior superior ili;)c spine. The examiner prevents ~nt~ she will have to transpose the reading so that 90 degrees lSequivalent [0 0 degrees. For example, an acrual reading of 90 hip rotation by m;linraining a firm grasp at the subject's knee with her ocher hand. 9;~grees is recorded as 0-30 degrees.

202 PA RT III LOWER·EXTREMITY TESTING MEDIAL (INTERNAL) ROTATION Stabilization Motion occurs in a transverse plane around 3 vertical \\r:lbilizt: rhe diswl t\"lld of the.: fClIlur 10 prc\\'(:nr ahduCk axis when the subject is in anatomical position. The lio!l, adducriofl. or furrher tlc.::xioll of the hip. Avoid rOta- mean adult values fot the ROM in medial rotation are liollS ;lfld 1:1[(\"r;11 tilting of d1(, pelvis. 32 degrees according Roach and Miles7 and 40 degrees accotding to the AMA. 4 Sec Tables 8-1, 8-2, 8-3, and Testing Motion 8-5 for additional ROM information. PI:h.:t..: one hand :U !Ill' disul lemur !O pro\\'ide stabiliza_ Testing Position lion ;'Inti lISC rhl: ot!lt.:r h:llld:H tht:: distal rihi:l 10 mOve the lowcr lcg laterally. Thl' hand performing dlL' motion also Scat the subject on a supporting surface, with the knees holds rhe 10\\\\,(;1' leg ill ;l IlcuHal posirion to pn:vell! rota~\", flexed to 90 degtees over the edge of the sutface. Place (ion al the klH.T joim (Fig. S-23). The end of rhe ROM the hip in 0 degtees of abduction and adduction and in (I,,:CUfS whell ;lnt:ltlprS ar n..:\"i~t;IIl(t: an: tde :lnd artempts· 90 degrees of flexion. Place a rowel roll under the distal :1£ IUfdH:f motion (aW.l' rilling of rill: pelvis Of latcral : end of the femur ro maintain the femur in a horizontal flexion ot t'lll· lfunK. plane. FIGURE 8-13 TIlt' Idt ImH'f l'xrrelllitv ,If rhe (:lid of rh(,.' ROM (If hip lI1l'Ji:d ror,nioll. nlll' nf lhl' O:.lll;iner\\ h:l11ds is p!:Jcrd on thl' :>uhjt·<.:r's lhsl:d felllur to pr(,.·'TIlC hip fk·xioll ,lIh.l :Ihduceion, ?:. Hl'r othl'l\" h:wd pulls !ll(,.' lown Iq; I:Ht'r:llly.

CHAPTER 8 THE HIP 203 Normal End-feel Goniometer Alignment c- The end-feel is firm because of tension in the posterior See Figures 8-24 and 8-25. a- joint capsule and the ischiofemoral ligament. Tension in I. Center the fulcrum of the goniometer over the the following muscles may also contribute to rhe firm anterior aspect of the patella. end-feel: piriformis, obrurarorii (internus and exrernus), 2. Align the proximal arm so that it is perpendicular gemelli (superior and inferior), quadratus femoris, to the floor or parallel to the supporting surface. ~a- gluteus medius (posrerior fibers), and gluteus maxim us. 3. Align the distal arm with the anterior midline of :he the lower leg, using the crest of the tibia and a Iso point midway between the two malleoli for refer- cncc. FIGURE 8-25 At the end of hip medial rotation ROM, the proximal arm of the goniometer hangs freely so that it is perpendicular co the Ooor. URE 8-24 In the starring position for measuring hip dial rotation, the fulcrum of the goniometer is placed over patella. Both arms of the instrument are cogcrher. \"

204 PART III LOWER-EXTREMITY TESTING LATERAL EXTERNAL ROTATION Stabilization Motion occurs in a transverse plane around a longitudi- Suhilil'.l: thl' disLd l'lId or\" rhl: femur to prevcll( abduction nal axis when the subject is in anammical position. The or further tln:ioll ot Ihe hip. Avoid ro{;uioll ;llld lateral mean ROM values for lateral rotation are 32 degrees tilting of dw pl.,·I\\'i~. according to Roach and Miles7 and 50 degrees according to the AMA 4 See Tables 8-1, 8-2, 8-3, and 8-5 for addi- Testing Motion . , . . . . . ,~ tional ROM information. 1'1:1(,; (lilt.' 11:1I1l.l;l1 {he thsra, lelllur III provldl' s£ahdlz;mon\"t;. . . Testing Position ;llld pb.:c lhl' or!l1.:r h;lIld Oil rht: diswl (ihllb w move the~~' ~ !OWL'!' kg medially (Fig. 1-i-26). ThL' h'lr\\<.! on till: fibula:':ijx~ f Seat the subject on a supporting surface with knees flexed to 90 degrees over the edge of the surface. Place the hip also prnTIltS r\\lf,Hioll ,It the knl'l' joinL The L'l1d of thd~; ; in 0 degrees of abduction and adduction and in 90 degrees of flexion. Flex the contralateral knee beyond 90 mot lOll O((lIrs when fL'si\",r:lIlL'c IS kit alld am.\"l1lpts at.;:¥0i .-, degrees to allow the hip being measured to complete its full range of lateral rotation. ol':on·I'I.:()iIlill~ rill.: n::-.isulll\"l' (;WSl\" rihin~ of rh<.: pelvis ~~J trunk I:H<.:ral flt.:.'\\ioll. ' FIGURE 8-26 Thi.' letl 10\\\\'l.:f cx(n:lllilv is at £lit: end of RO\\\\ (If hip loner:ll rot;Hioll. Till: l\")CllIli;llT pbCloS onc lund on rhc \",llhiclT\\ di~l\"ll tl'lllUr ((I I'rlOVl°1\\t hl,th hip flexion :lnd hip ,lhdu(.'iiHII. Thlo sulllc,,:! :lSSi:-'b with :-'l:lhili'l.;ltion hy pl:H.:ing her h:llId:> on [he sllpponill~ :'>urt;lL:l' ;lIld shiflillg her wci~IH over h:.:r kit hi1'o Thl' >;\"bin.:r flloxcs her ri~ht klll'l.' to :I!lO\\\\, [he left lower ('.'\\rrclllity (() (olllpl(:tl.' tht: RO\\1.

CHAPTER 8 THE HIP 205 Normal End-feel Goniometer Alignment The end-feel is firm because of tension in the anterior See Figures 8-27 and 8-28. joint capsule, iliofemoral ligament, and pubofemoral 1. Center rhe fulcrum of the goniometer over the ante· ligament. Tension in the anterior portion of the gluteus rior aspect of the patella. medius, gluteus minimus, adductor magnus, adductor 2. Align rhe proximal arm so rhat ir is perpendicular longus, pectineus, and piriformis muscles also may to the floor or parallel to the supporting surface. m contribute to the firm end-feel. 3. Align the distal arm with the anterior midline of the ,e lower leg, using the crest of the tibia and a point la midway between the two malleoli for reference. he at or fiGURE 8-27 Goniometer alignment in the starting position FIGURE 8-28 At the end of hip lateral rotation ROM the r measuring hip lateral rotation. examiner uses one hand to support the subject's leg and to maintain alignment of the distal goniometer arm.

206 PART J II lOWER-EXTREMITY TESTING Muscle Length Testing Procedures: T 12 Hip l1 l2 HIP FLEXORS THOMAS TEST L3 l4 The iliacus and psoas major muscles flex rhe hip in the l l i a c u s - -L l5 sagittal plane of motion. Other muscles, because of their attachments, creare hip flexion in combination with other motions. The rectus femoris flexes the hip and extends the knee. The sartorius flexes, abducts, and laterally 2>\"\",'--- Psoas major /\",./:\\0.] rotates the hip while flexing the knee_ The tensor fasciae Tensor laseia Iatae abducts, flexes, and medially rotates the hip and lata extends the knee. Several muscles that primarily adduct the hip, such as the pectineus, adductor longus, and adductor brevis, also lie anterior to the axis of the hip joint and can contribute to hip flexion. Short muscles ;Fi{;;/;;~ that flex the hip limit hip extension ROM. Hip extension can also be limited by abnormalities of the joint surfaces, shortness of the anterior joint capsule, and short - - - - Sartorius iliofemoral and ischiofemoral ligaments. The anatomy of the major muscles that flex the hip is illustrated in Figure 8-29A and B. The iliacus originates :>'···5\"l proximally from the upper two thirds of the iliac fossa, the inner lip of the iliac crest, the lateral aspect (ala) of the sacrum, and the sacroiliac and iliolumbar ligaments. It inserts distally on the lesser trochanter of the femur. The psoas major originates proximally from the sides of A the vertebral bodies and intervertebral discs of T12-LS, Anterior superior iliac ./.=:=--~ spine and the transverse processes of Ll-L5. It inserts distally on the lesser trochanter of the femur. These two muscles are commonly referred to as the iliopsoas. If the iliopsoas is short, it limits hip extension without pulling the hip in --Anterior iliac + - - \\ , spine another direction of motion; the thigh remains in the sagittal plane. Knee position does not affect the length of the iliopsoas muscle. The rectus femoris arises proximally from two tendons: the anterior tendon from the anterior inferior iliac spine, and the posterior tendon from a groove supe- rior to the brim of the acetabulum. It inserts distally into Reclus femoris the base of the patella and into the tibial tuberosity via the patellar ligament. A short rectus femoris limits hip extension and knee flexion. If the rcctus femoris is shorr, and hip extension is attempted, the knee passively moves into extension to accommodate the shortened muscle. Somerimes, when rhe rectus femoris is shortened and hip extension is attempred, rhe knee remains flexed bur hip extension is limited. Patella Patellar The sartorius arises proximally from rhe ASIS and the ligament upper aspect of rhe iliac notch. It inserts distally into the B proximal aspecr of the medial tibia. If the sartorius is short it limits hip extension, hip adduction, and knee extension. If the sartorius is shan and hip extension is attempted, the hip passively moves into hip abduction and knee flexion to accommodate the short muscle. FIGURE 8-29 An anterior view of the hip nexor muscles.

CHAPTER 8 THE HIP 207 The tensor fasciae latae arises ptoximally from the muscles are short and hip extension is alCempted, the hip anterior aspect of the outer lip of the iliac crest and the passively moves into adduction to accommodate the lateral surface of the ASIS and iliac notch. It inserts shortened muscles. distally into the iliotibial band of the fascia lata about one-third of the distance down the thigh. The iliotibial Starting Position . band inserts into the lateral anterior surface of the prox- ,',.. Imaltibia. A short tensor fascia latae can limit hip adduc- Place the subject in the silCing position at the end of the ',:;,}·,\\/:/,tion, extension and lateral rotation, and knee flexion. If examining table, with the lower thighs, knees, and legs hip extension is alCempted, the hip passively moves into off the table. Assist the subject into the supine position '.'\"abduction and medial rotation to accommodate the short by supporting the subject's back and flexing the hips and Zi/(:)/muscle. knees (Fig. 8-30). This sequence is used to avoid placing a strain on the subject's lower back while the starting test ..';;;! The pectineus originates from the pectineal line of the position is being assumed. Once the subject is supine, flex the hips by bringing the knees toward the chest just :;-i;?\"pubis, and inserts in a line from the lesser trochanter [0 enough to flalCen the low back and pelvis against the . the linea aspera of the femur. The adductor longus arises table (Fig. 8-31). In this position, the pelvis is in aboUlIO degrees of posterior pelvic till. Avoid pulling the knees proximally from the anterior aspect of the pubis and tOO far toward the chest because this will cause the low inserts distally into the linea aspera of the femur. The adductor brevis originates from the inferior ramus of the back to go into excessive flexion and the pelvis to go into pubis. It inserts into a line that extends from the lesser trochanter to the linea aspera and the proximal part of an exaggerated posterior tilt. This low back and pelvis the linea aspera JUSt posterior [0 the pectineus and prox- position gives the appearance of tightness in the hip flex- \"imal part of the adductor longus. Shortness of these ors when, in fact, no tightness is present. .. !puscles limits hip abduction and extension. If these AGURE 8-30 The examiner assists the subject into the starting position for testing the length of the hip flexors. Ordinarily the examiner srands on the same side as the hip being tested to visualize the hip region and ulke measurements, but the examiner is standing on the contralateral side for the photograph.

208 PA RTill LOWER-EXTREMITY TESTING FIGURE 8-31 The starting position for testing the It:ngrh of the hip flexors. Both knees and hips are flexed so that the low back and pelvis afe flat on the examining table. ~;,\"j;'>rn Stabilization lowering [he [high toward [he examining table. The is relaxed in approximately 80 degrees of flexion. The Ei[her [he examiner or [he subject holds [he hip not being lower extremity should remain in [he sagittal plane. tested in flexion (knee toward the chest) to maintain the low back and pelvis flat against the examining table_ If [he thigh lies fla[ on [he examining [able and the knee remaios in 80 degrees of flexion, [he iliopsoas Testing Motion rectus femoris muscles are of normalleng[h\" (Figs, and 8-33). A[ [he cnd of [he [est, [he hip is in 10 degrees Information as to which muscles arc short can be gained of extension because the pelvis is being held in 10 degrees by varying the position of [he knee and carefully observ- of posterior [ilt. A[ [his poinr, [he [est would be ing passive motions of the hip and knee while hip ex[en- concluded. l;\",;\"}';li.1 sion is attempted. Ex[end [he hip being tested by

CHAPTER 8 THE HIP 209 FIGURE 8-32 The end of the motion fot testing the length of the hip flexors. The subject has normal length of the right hip flexors: the hip is able to extend to 10 degrees (thigh is flat on table), the knee remains in 80 degrees of flexion, and the lower exrremicy remains in the sagittal plane. Iliacus Psoas FIGURE 8-33 A laretal view of the hip showing the hip flexors at the end of the Thomas test.

210 PART III LOWER-EXTREMITY TESTING If the thigh does not lie flat on the table, hip extension Normal End-feel is limited, and further testing is needed to determine the cause (Fig. 8-34). Repeat the starting portion by flexing When the knee remains flexed at the end of hip extension the hips and btinging the knee toward the chest. Extend ROM, the end-feel is firm owing to tension in the rcctus the hip by lowering the thigh towatd the examining table, femoris. When the knee is extended at the end of hip but this time support the knee in extension (Fig. 8-35). extension ROM, the end~feel is firm owing to tension in When the knee is held in extension, the rectus femoris is the anterior joint capsule, iliofemoral ligament, slack over the knee joint. If the hip extends with the knee ischiofemoral ligamem, and iliopsoas muscle. If one Or held in extension so that thigh is able to lie on the exam- more of the following muscles are shortened they may ining table, the rectus femoris can be ascertained to have also contribute to a firm end-feel: sartorius, tensor fasciae been short. If the hip cannot extend with the knee held in larae, pectineus, adductor longus, and adductot brevis. extension and the thigh does not lie on the examining rabie, the iliopsoas, anterior joint capsule, iliofemoral Goniometer Alignment ligamem, and ischiofemoral ligamem may be short. See Figure 8-36. When the hip is extending towatd the examining table, observe catefully to see if the lowet extremiry stays in the 1. Cenrer the fulctum of the goniometet OVet the sagittal plane. If the hip moves into latetal rotation and lateral aspect of the hip joim, using the greatet abduction, the sartorius muscle may be short. If the hip trochanter of the femur for teference. moves into medial rotation and abduction, the tensor fasciae latae may be short. The Ober test can be used 2. Align the proximal arm with the Iatetal midline of specifically to check the length of the tenSOt fasciae latae. the pelvis. If the hip moves into adduction, the pectineus, adductor longus, and adductot brevis may be short. Hip abduction 3. Align the distal arm with the lateral midline of the ROM can be measured to test mate specifically for the femur, using the lateral epicondyle for teference. length of the hip adductors. FIGURE 8-34 This subject has fcstricrcd hip extension. Her thigh is unable to lie on the table with the knee flexed co 80 degrees. Further testing is needed to determine which structures arc ShOft.

CHAPTER 8 THE HIP 211 FIGURE 8-35 Because the subject had restricted hip extension at the end of the testing motion (see Fig. 8-34), the testing motion needs ro be modified and repeated. This time, the knee is held in extension when the extremity is lowered toward the table. At the end of the rcst, the hip extends to 10 degrees, and the thigh lies flat on the rable. Therefore. one may conclude that the recrus femoris is short and that the iliop- soas, anterior joint capsule, and iliofemoral and ischiofemoral ligaments are of normal length. FIGURE 8-36 Goniometer alignment for measuring the length of the hip flexors.

PA RT III LOWER-EXTREMITY TESTING The hamstring muscles, composed of the semitendinosus, Semitendinosus + 1 - + - Biceps lemoris semimembranosus, and biceps femoris, cross two joints-the hip and the knee. When they contract, they (long head) extend the hip and flex the knee. The semitendinosus originates proximally from the ischial tuberosiry and Semimembranosus - - - t l Biceps lemoris insertS diStally on the proximal aspect of the medial (short head) surface of the tibia (Fig. 8-37A). The semimembranosus originates from the ischial tuberosiry and inserts on the A posterior medial aspect of the medial condyle of the tibia (Fig. 8-37B). The long head of the biceps femoris origi- nates from the ischial tuberosiry and the sacrotuberous ligament, whereas the short head of the biceps femoris originates proximally from the lateral lip of the linea aspera, the lateral supracondylar line, and the lateral ~'i(;iil intermuscular septum (Fig. 8-37A). The biceps femoris \"\" ,;,,\",'.' insertS OntO the head of the fibula with a small portion extending to the latetal condyle of the tibia and the lateral collateral ligament. Because the hamstrings are two-joint muscles, short- ness can limit hip flexion and knee extension. If hamstrings are short and the knee is held in full exten- sion, hip flexion is limited. However, if hip flexion is limited when the knee is flexed, abnormalities of the joint surfaces, shortness of the posterior joint capsule, or a short gluteus maximus may be present. Starting Position Place the subject in the supine position, with both knees extended and hips in 0 degrees of flexion, extension, abduction, adduction, and rotation (Fig. 8-38). If possi- ble remove clothing covering the ilium and low back so the pelvis and lumbar spine can be observed during the tcst. -+-1--- SemimembranQsus B FIGURE 8-37 A posterior view of the hip showing the hamstring muscles (A and B).

CHAPTER 8 THE HIP 213 Stabilization lower extremiry is lying on the examining table. An ante- rior pelvic tilt decreases the disrance that the leg being Hold the knee of the lower extremiry being tested in full tested can lift off the examining table, thus giving the extension. Keep the other lower extremiry flat on the appearance of less hamstring length than is actually pres- examining table to stabilize the pelvis and prevent exces- ent. To remedy this situation, have the subject flex the sive amounts of posterior pelvic tilt and lumbar flexion. hip not being tested by resting rhe foor on the table or \",. Usually, the weight of the lower extremiry provides by supporting the thigh with a pillow (Fig. 8-41). This iadequate stabilization, but a strap securing the thigh to position slackens the short hip flexors and allows the :the examining table can be added if necessaty. low back and pelvis to flatten against the examining table. Be careful to avoid an excessive amount of poste- n;iT~sting Motion rior pelvic tilt and lumbar flexion. :.:hex the hip by lifting the lower extremiry off the table If the subject has short lumbar extensors, the low :·«(Figs. 8-39 and 8-40). Keep the knee in full extension by back has an excessive lordotic curve and the pelvis is in an anterior tilt. The distance that the leg can lift off the \"applying firm pressure to the anterior thigh. As the hip examining table is decreased if the pelvis is in an anterior flexes, the pelvis and low back should flatten against the tilt. This gives the appearance of less hamstring length examining table. The end of the testing motion occurs than is actually present. In this case, the examiner needs when resistance is felt from tension in the posterior thigh ro carefully align the proximal arm of the goniometer and furrher flexion of the hip causes knee flexion, poste- with the lateral midline of the pelvis when measuring hip rior pelvic tilt, or lumbar flexion. If the hip can flex to flexion ROM, not being misled by the heighr of the between 70 and 80 degrees with the knee extended, lower extremiry from the examining table. the teSt indicates normal length of the hamstring .,muscles. 32 Normal End-feel ;ii',;:, Shortness of muscles in the hip and lumbar region i~fluences the results of the straight leg raising test. If the The end-feel is firm owing to tension in the semimem- F~~bject has shorr hip flexors on the side that is not being branosus, semitendinosus, and biceps femoris muscles. :\"t,sted, the pelvis is held in an anterior tilt when that \"'j ,~.:: ' ~';'/ ' ! ..- !: !.; FIGURE 8-38 The starting position for testing the length of the hamstring muscles.

214 PA RT III LOWER-EXTREMITY TESTING 2. Align the proximal arm with the lateral midline of Goniometer Alignment the pelvis. See Figure 8-42. 3. Align the distal arm with the lateral midline of the I. Center rhe fulcrum of the goniometer over the femur, using the lateral epicondyle for reference. lateral aspect of rhe hip joint, using the greater trochanter of the femur for reference. k / _/j;; FIGURE 8-39 The end of the testing motion for the length of the hamstring muscles. The subject has normal length of the hamstrings: the hip can be passively flexed to 70 to 80 degrees with the knee held in full extension. This test is also called the straight leg raise tcst. J FIGURE 8-40 A lateral view of the hip showing the biceps femoris at the end of the testing motion for the length of the hamstrings.

C HAP T ER .8 THE HIP 215 FIGURE 8-41 If the subject has shortness of the contmlatcral hip flexors, flex the contralateral hip to prevent an anterior pelvic tilt. FIGURE 8-42 Goniometer alignment for measuring the length of the hamstring muscles. Another cxam~ ince will need to take the mcasurcmcm while the first examiner supporrs the leg being tested.

216 PART III LOWER-EXTREMITY TESTING •• Stabilization The tensor fasciae latae crosses two joints-the hip and Place one hand on the iliac crest to stabilize the pelvis. knee. When this muscle contracts, it abducts, flexes, and Firm pressure is usually required to prevent the pelvis medially rotates the hip and extends the knee. The tensor from laterally tilting during the testing motion. Having fascia latae arises proximally from the anterior aspect of the patient flex the bottom hip and knee can also help to the outer lip of the iliac crest, and the lateral surface of stabilize the trunk and pelvis. the ASIS and the iliac notch (Fig. 8-43). It attaches distally into the iliotibial band of the fascia Iatae about Testing Motion one third of the way down the thigh. The iliotibial band inserts into the lateral anterior surface of the proximal Support the leg being tested by holding the medial aspect tibia. If the tensor fascia Iatae is short it limits hip adduc- of the knee and the lower leg. Flex the hip and the knee tion and, to a lesser extent, hip extension, hip lateral to 90 degrees (Fig. 8-44). Keep the knee flexed and move rotation, and knee flexion. the hip into abduction and extension to position the tensor fasciae latae over the greater trochanter of the Starting Position femur (Fig. 8-45). Test the length of the tensor fasciae latae by lowering the leg into hip adduction, bringing it Place the subject in the sidelying position, with the hip toward the examining table (Figs. 8-46 and 8-47). Do being tested uppermost. Position the subject near the nOt allow the pelvis to tilt laterally or the hip to flex - edge of the examining table, so that the examiner can because these motions slacken the muscle. Keep the knee stand directly behind the subject. Initially, extend the flexed to control medial totation of the hip and to main- uppermost knee and place the hip in 0 degrees of flexion, tain the stretch of the muscle. If the thigh drops to slightly extenslon, adduction, abduction, and rotation. The below horizonral (10 degrees of hip -adduction), the test patient flexes the bottom hip and knee to stabilize the is negative and the tensor fasciae latae is of normal trunk, flatten the lumbar curve, and keep the pelvis in a length]! If the thigh remains above horizontal in hip slight posterior tilt. abduction, the tensor fasciae latae is tight. FIGURE 8-43 A lateral view of the hip showing the tensor fasciae latae and iliotibial band.

CHAPTER 8 THE HIP 217 FIGURE 8-44 The first step in the testing motion for the length of the tensor fasciae larae is to flex the hip and knee. FIGURE 8-45 The next step in the testing morian for the length of the tensor fasciae Imac is [0 abduct and extend the hip. These first (WO steps in the testing motion will help position the tcnsor fasciae latac over the greater trochanter of the femur.

218 PA RTill LOWER-EXTREMITY TESTING Some authors have stated that the tcnsor fasciae Jatae rcst,3! but extreme care must be raken ro avoid medial is of normal length when the hip adducts to the examin- rotation of the hip as the leg is lowered into adduction. ing rabJe. S1 ,52 However, srabilizmion of the pelvis to This change in test position is called a modified Ober test. ptevent a latetal tilt and avoidance of hip flexion and medial rotation limit hip adduction to 10 degtees during Normal End-feel the testing motion, causing the thigh to drop slightly The cnd-fecl is firm owing to tension in the tensor faScia below the horizontal position. 32 Even more conservative lata. hip adduction values have been reported as normal by Cade and associates,\" who found that only 7 of 50 Goniometer Alignment young female subjects had normal (or not short) bent leg See Figure 8-48. Ober test values when the horizontal leg position was used as the test parametet. 1. Center the fulcrum of the goniometer over the Asi of the extremity being measured. Note that at least 0 degrees of hip extension is needed to perform length resting of the tensor fascia lara. If the 2. Align the proximal arm with an imaginary Ii extending from one AS IS to the other. iliopsoas is right, it prevents the proper positioning of the tensor fascia lata over the greater trochanter. If the rectus 3. Align the distal arm with the anterior midline of th femoris is short, the knee may be extended during the femur, using the midline of the patella for reference. FIGURE 8-46 The end of the testing morian for [he length of the [cnsor fasciae larac. The cxnmincr is firmly holding the iliac crest to prcvcnr a latcral tilt of thc pelvis while the hip is lowered inca adduction. No flexion or medial rotation of the hip is allowed. The subject has a normal length of the tensor fasciae lawe; the thigh drops to slightly below horizontal.

CHAPTER 8 THE HIP 219 FIGURE 8-47 An anterior view of the hip showing the tcnsor fasciae lame at the end of the Obef tcSt. FIGURE 8-4B Goniometer alignment for measuring the length of the tensor fasciae larae. The examiner stabilizes the pelvis and positions the leg being tested while another examiner takes the measurement. If another examiner is not available, a visual estimate will have to be made.

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IJI.. l'I :11: IlHltrn:r1r me.b~lrirlg k-1IJ.:th 01 rill' illoril.i.t1 b:lIld :llld reb fed hq' ~ttlt..:f1Jr(·S: :\\ corrd;lliIl1l:l1 ;l1la!y,is CIt four ~Hlduc­ lion I\\,SIS, :\\bsfr.h,:t PLllrorlll Pn'Sl'IIf.\\liorl :l! APTA \\,tid-W'jnter, T~'x.J Ol\"lhop SPOrtS Phys Ther 31:,\\12, 2UOI.

-le- nd ces en- lck mg hip ,I \\ Iller 'no- n in 103, The Kneenkle Orts eotS 955, Inge • Structure and Function joint, the proximal joint surfaces are the convex medial and the lateral condyles of the distal femur (Fig. 9-1). Ther Posteriorly and inferiorly, the longer medial condyle is r.lers, Tibiofemoral and Patellofemoral Joints Anatomy separated from the lateral condyle by a deep groove Jhe knee is composed of two distinct articulations called the intercondylar notch. Anteriorly, the condyles enclosed within a single joint capsule: the tibiofemoral are separated by a shallow area of bone called the joint and the patellofemoral joint. At the tibiofemoral femoral patellar surface. The distal articulating surfaces are the two shallow concave medial and lateral condyles on the proximal end of the tibia. Two bony spines called the intercondylar tubetcles separate the medial condyle from the lateral condyle. Two joint discs called menisci are attached to the articulating surfaces on the tibial condyles (Fig. 9-2). At the patellofemoral joint, the artic- -t--Femur Anterior cruciale ligament Posterior cruciate ligament Femur -1,.--+-- Patella Lateral epicondyle ......._ t;c. ,))),~-Medial epicondyle - 1 - - Medial condyle lateral condyle --Iii- Medial condyle Lateral meniscus-f~~~~~ Medial condyle ~;g;;ifffif----:Medial meniscus Intercondylar Lateral (fibular) Medial (tibial) tubercles collateral ligament , collateral ligament ..-I---Tibia Fibula Tibia right knee showing the FIGURE 9-2 An anterior view of a right knee in the flexed position showing femoral and tibial condyles, medial and lateral menisci, and cruciate and collateralligamenrs. 221

222 PART III LOWER· EXTREMITY TESTING ulating surfaces are the posterior surface of rhe patella portion of the :Krivt' eX(l'nsion rangl..· of. llloriOI1 (ROM), and the femoral patellar surface (Fig. 9-3). :111WIll~Hi( ror:Hion prOdll(L'S Wh~H is rekrrcd W ilS either The joint capsule that encloses borh joints is large, thl..· st:rl\"w-holl1t' C11l'l\".\"hani::'l1l, or '''locking,'' of thl' knee. loose, and reinforced by tendons and expansions from To hegin flexion, thl- klKt.' must he 1I11lot:ktd hy rotarion ;:\" the surrounding muscles and ligaments. The quadriceps 111 {'hl' opposite dirl'l:tioll. For eX;ll1lpk', during tcndon, patellar ligament, and expansions from the Jlon-\\\\\"l:ighr-hl'aring al'ti\\\"t klH..'(· extension, I~HI.:r<l! rOta- extensor muscles provide anterior stability (see Fig. 9-3). tion 01 !Ill\" tibia oculrs during the last 10 to 15 degrees'- The lateral and medial collateral ligaments, iliotibial of (,:x[ef]sion to l()(k the klll'e,-~ -r<) ulllot:k tht knee, the band, and pes anserinus help to provide medial-lateral lihi~l rot,Hes mediall}'. -rhis rotation is not lllldn \\'()lun~ stability, and the knee flexors help to provide posterior r:ll'y l..\"lllHrol ,llld should !lot hc confused with the vol un- stability. In addition, the tibiofemoral joint is reinforced l;Hy rot,HiOl! f1H)Velllc.:llt possible at the joint. by the anterior and posterior cruciate ligaments, which Passive RO~vt in flexion is geller;llly (ollsidtrc:d to be are located wirhin the joinr (see Fig. 9-2). hl.:tW(TII 130 :llld I-W dq.~n:es. The ran~(' of (,'xtcllsion Osteokinematics hl·yOlH.I 0 dq.~rn's is ahout -\" to 10 degrees ill young chil. drell, whereas 0 d(,:grCl'~ is l,-oJlsidern.1 In he.: within·; The tibiofemoral joint is a double condyloid joint wirh 2 Ilorlll:ll limirs for ;ldlllr~, • Thl' gre:ltl',,;r range of \\'ohm· c:lcgrees of freedom. Flexion-extension occurs in the rar~\" kllt:e roration (l((llr~ ;H 90 dq~r(,'es of t1l'xioll~ at this sagittal plane around a medial-lateral axis; rotation poilH. ahout 45 degn.:e:'> of bter;1! ror;Hioll and 15 occurs in the transverse plane around a vertical (longitu- l.lt,-grn·s of medi~ll ror;uioll arc possible dinal) axis. I The incongruence and asymmetry of the Arthokinematics tibiofemoral joint surfaces combined with muscle activ- ity and ligamentous restraints produce an automatic Th(· in(\"ongruc!lcl' of the tihiofcll1or:l! joint :lIld rhe rotation. This automatic rotation is involuntary and that the femoral arricul;Hing sllrLlccs arl' brgt:r rhan occurs primarily at the extreme of extension when [ihi~ll arriculating sllrfac('s, dict,1f('S thar when the motion stops on the shorter lateral condyle but continues femoral condyles Jrc moving 011 the tihial ((lllllyies (in on the longer medial condylar surface. During the last \\\\'('ig,h[-hearill~ situation), the femoral condyl<.:s must nnd slide to rt'nuin Oil the tihi;l. In \\\\'eighr-hl'~lring JOIl. the fClllor:lll\".'ondyks roll posreriorly and slide riorly. The lllcnisci follo\\\\\" the roll of thl' l.\"ondyles I Femur distorting posraiorly in flexion. In extl'nsion. I Patellar . Semitendinosus femoral condyles roll :1nteriorly ,1nd slide posrl'fiorly.1 In quadriceps I tendon thf---- Gracilis rhl' last porrion of l'xtensioll, motion srops Olt the ..~ femoral londy-le, bur sliding I..\"onrinul's Oil the medial fl~l1loral cond~'le co produce locking of the knee. ---+§ Patella In non-wl'ight-bcaring ;lCrivc Illotion, thl' concave ribial arri(ulating surfOlccs slide on tht.· l.\"onvex ('undylcs in the sallle dirc(rion as the mOV('lllcnr of shaft of the tibi,l. \"fhe tibi;lI condyles slide postcriorly the fl'm()r~ll condyles during flexion. During from full flexion, the tibial t:()Ildvles slick' :Hltcriorly the fcmoral t:ondylC's, Patellar Sartorius 'fhe patella slides sllpcriorly in extension and ligament ,.. uri)\" in flexion. SOl1le p;w:II:H rorarion and tilting aOCOln-.' pany the sliding durinp. tlexion ~lIld extension, I Pes anserinus Capsular Pattern -t--Tibia Thl' c<lpsllbr p.lttcrn at the knee is ch:u;:Krl'fized by slllaller limitation 01 l'xtension than of flexion and FIGURE 9-3 A view of 3 right knee showing the medial aspect, restriction of rotarions.-!.\" rritz and associ:1tl's(, found where the cut tendons of the three muscles that insert into the thar paricIHs with ;1 capsular partcrIl defincd as a rario of anteromedial aspect of the tibia make up the pes anserinus, Also included are the patellofemoral joint, the patellar ligament, and cxrension loss to tkxion loss hetwecn 0.03 and 0.50, the patellar tendon. wefe 3.2 times more likely to have arthritis or :lrrhroses, of thl' knee. Hayes feported ;J mean ratio of exrension/, loss to flexion loss of 0.40 in a stLldy of 79 patil'nts with:..:, OStef);l rth ritis, ~\".S

CIiAPTER 9 THE KNEE 223 ._Research Findings who found that newborns lacked 14 degrees of knee eXlension. The extension limitation gradually disappears \";.: as shown by comparing Tables 9-2 and 9-3. Broughton, Table 9-1 provides knee ROM values from selected \\Vright, and Menelaus!? measured extension limitations in normal neonates al birrh and again at 3 months and 6 sOurces. The numbet, age, and gendet of the subjects months. Ar birth, 53 of the 57 (93 percent) neonales had .measured to obtain the AMA9 values are unknown. extension limirarions of 15 degrees or greater, whereas BOo~e and Azen 10 used a universal goniometer to meas- only 30 of 57 (53 percent) infants had extension limila- ute active ROM on male subjects. Roach and Miles\" tions at 6 months of age. The mean reduction in exten- sion limitations was 3.5 degrees per month from birth to also used a universal goniometer co measure active 3 months, and 2.8 degrees between 3 and 6 months (sec Table 9-3). The 2-year-olds in the srudy conducted by .'ROM, but Iheir measuremenls were oblained from bOlh Wanatabe and associates!6 (sec Table 9-3) had no Jn,t,:,,i.l~s and females. evidence of a knee extension limitation. ',~(,: ,. Extension beyond 0 degrees at the knee is a normal iEffects of Age, Gender, and Other Factors finding in young children bur is not usually observed in adults,' who may have slightly less than full knee exten- i:·\"i·. ,···.·\" sion. Wanatabe and associates'6 found rhal Ihe two-year- olds had up to 5 degrees of extension. This finding is ii\\j;fci' similar ro Ihe mean of 5,4 degrees of extension noted by Boone\" for rhe group of children between 1 year and 5 ;}g~> years of age. Beighlon, Solomon, and Soskolne,19 in a study of joint laxity in 1081 males and females, found Llmiiations of knee extension at birth are normal and thaI joint laxity decreased rapidly throughout childhood in both genders and decreased at a slower rate during -,mtilar 10 extension limilalions found at birrh ar the hip adulthood. The authors used a ROM of greater than 10 degrees of knee eXlension as one of Ihe criteria of joint joiliLWe have chosen to use the term \"extension limita- laxity. Cheng and colleagues/o in a study of 2360 Chinese children, found that Ihe average of 16 degrees of tion\" rather than \"flexion contracture\" because contrac- knee extension ROM in children of 3 years of age tUre refers to an abnormal condition caused by fixed . musele shorrness, which may be permanentY Knee ooehsion limitalions in the neonate gradually disappear, Iild- extension, inslead of being limited, may become iXtessive in the toddler. Waugh and colleagues lJ and .If~ws· and coworkers i-\"~;;i\"~::\"lOximately 15 to \" found that f newborns lacked 20 degrees o knee extension_ 8K\\varze and Denton,15 in a study of 1000 neonates girls and 473 boys) in the first 3 days of life, found n extension limitation of 15 degrees. These findings J£~~.with the findings of Wanatabe and associates,16 :%Jf~~>~ !,BLE 9-2 Knee Extension limitations in Neonates 6 Hours to 7 Days of Age: Mean Values In Degrees tandard deviation. were obtained from passive range of motion measurements with use of a universal goniometer.

224 PA R Till LOWER·EXTREMITY TESTING TABLE 9-3 Knee Range of Motion in Infants and Young Children 0 to 12 Years of Age: Mean Values in Degrees . (50) = Standard deviation. • Indicates extension limitations. t Indicates extension beyond 0 degrees. decreased ro 7 degrees by the rime the children reached 9 ~elH{\"rs. No ditltTCllCl:S Weft found in knee ROM: years of age. A comparison of the knee extension mean hL\"(WI.:L'11 tht group aged (lO to 69 )',,:ar5 :l1ld ;l group age~_; values for the group aged 13 to 19 years in Table 9-4 75 ro X4 years. However. :\\\\'cr:l~l' valll!.'s indicHed that with the extension values for the group aged 1 ro 5 years rhe suhjecrs had <l limit;uioll in t'~(,(,l1SiOIl (inability t in Table 9-3 demonstrates the decrease in extension that :lfuin ,I I1tlltT,t1 O-ckgrcl: surring posirion). This findingC ; wa~ simibr w the loss 01 (,xlt,:Jlsinn notcd at the hip,' occurs in childhood. ('lhem\", ,llld first llleut:lrsnphaLlngC',ll {\\lTPi joints. The In Table 9-4, the mean values obtained by Boone\" are 2-degrcc eXfension lirnitation found ~H the knee was from male subjects, whereas the values obtained by much smaller dUll dUf found at the hip joinr, Using Roach and Miles 11 are from both genders. If values two Luge studies of :Hlult rn~llcs ;lS the basis for their conclusions, fhe AnH:ricall Ass()('i<.ltiOIl of Orthopaedic presented for rhe oldest groups (those aged 40 ro 74 Surgeons (:\\:\\OSl Handbook' Stal('S [hat exrension limi:\" years) in both studies are compared with the values for t.1tions of 2 degrees (SD = 3) ;lr(' considered ro be norma in ~H.Jlllts\" the youngest group (those aged 13 ro 19 years), it can be Extension limitations gn:ar('r (han:) degrees in adult~ seen that the oldest groups have smaller mean values of l1l~l~' be consider<:d as kn('(' fkxion (onrracrures. These flexion. However, with a SD of 11 in the oldest groups, coI1tr~lc(Ures often occur in rhl' ddt.:r1y hC(i.H1sC of disease; Sl:'dl'IHary lifc.\"sly!es, and thl' l'ft\"l'cts of the aging procesS the diffetence between the youngest and the oldest Oil connective tissues. Mollinger and Steftan2 ! used a' groups is not more than 1 SD. Roach and Miles 11 uni'\"crsal goniomcter to assess knl'(' RO\\I among 11 concluded that, at least in individuals up to 74 years of Ilursing home residents with :lll :l\"cr:lge 'lgC of 83 years~ age, any substantial loss (greater than 10 percent of the TIlt.' authors found thilt only 1.3 pacem of d,(· subjects arc of motion) in joint mobility should be viewed as had full (0 degrcr:sl passi'>(' knee exrcll~ioll bilaterally. Thirty-seven of the 112 subjl:GS (33 pen':L'lH) had bilat abnormal and not attributable ro the aging process. The eral knl't' extension limitarions of 5 dl'~rces or !('ss bilat emIly> Forty-sevcll subj('([s {42 perc('n;) Iud greater tha-~~­ flexion values obtained by these authors were considet- I() degrccs of limirarions in t.'xrcnsioll (flexion comrac;_ ably smaller than the lSD-degree average value published by the AMA9. Walker and colleagues!1 included the knee in a study of active ROM of the extremity joints in 30 men and 30 women ranging in age from 60 to 84 years. The men and women in the study were selected from recreational (SO) = Standard deviation. p a \\ IT 8 a fI g m re c( ar

CHAPTER 9 THE KNEE 225 &tures). Residents with a 30-degree loss of knee extension. passive knee flexion ROM compared with males of the same age. However, the women had on average only 2 ;k0hiid an increase in resistance to passive motion and a loss degtees less knee flexion than the men. The women also had a higher body-mass index (BMI) than the men, which 0%;'~f ambulation. Steultjens and coworkers\" found knee may have contributed to their reduced knee flexion. ;'iijQexion contractures in 31.5 percent of 198 parients with Schwarze and Denton I S observed no differences owing to ~'9steoarthriris of the knee or hip. Generally a decrease in gender in a study of 527 girls and 473 boys aged 1 ro 3 ';\"l1¥c;tive assistive ROM was associated with an increase in days. ~(ljsabiliry but was action specific. The motions that had ';;We strongest relationship with disability were knee f1ex- Body-Mass Index Lichtenstein and associates28 found that among 647 -ricin, hip extension, and lateral rotation. A surprising find- communiry-dwelling elderly subjects (aged 64 ro 78 years), those with high BMI had lower knee ROM than ;t;i/Ig of this study was the strong relationship between theit counterpartS with low BMI. Severely obese elderly ~iiexion ROM of the left knee with flexion ROM of the subjects had an average loss of 13 degrees of knee flexion oiftight knee. ROM compared with nonobese counterparts. The 'iii Despite the knee flexion contractures found in the authors determined that a loss of knee ROM of at least 1 iii/elderly by Mollinger and Steffan,\" many elderly individ- degtee occurred for each unit increase in BMI. Escalante 'illals appear to have at least a functional flexion ROM. and coworkersH found that obesity was significantly )I'Jscalanrc and coworkers24 used a universal goniometer associated with a decreased passive knee flexion ROM. ;\"~f<.> measure knee flexion passive ROM in 687 commu- Sobti and colleagues29 found that obesity was signifi- ~~ry-dwelling elderly subjects between the ages of 65 and cantly associated with the risk of pain or stiffness at the ;,£79 years. More than 90 degrees of knee flexion was knee Ot hip in a survey of 5042 Post Office pensioners. {((bund in 619 (90.1 percent) of rhe subjects, The authors C{;a~ed a cutoff value of 124 degrees of flexion as being Functional Range of Motion ~)fithin normal limits. Subjects who failed to reach 124 \"grees of flexion were classified as having an abnormal Table 9-5 provides knee ROM values required for vati- ous functional activities. Figures 9-4 to 9-6 show a vari- 'OM. Using this criterion, 76 (11 percent) right knees ery of funcrional activities requiring different amounts of itd 63 (9 percenr) left knees had abnormal (limited) knee flexion. Among the activities measured by Jevesar assive ROM in flexion. and coworkers30 (stair ascent and descent, gait, and rising from a chair), stair ascent required the greatest range of ighron, Solomon, and Soskolne 19 used more rhan 10 knee morion. , rees of knee extension from 0 (hyperextension) as one ,their criteria in a study of joint laxiry in 1081 males Livingston and associates)1 used three testing stair- cases with different dimensions. Shorter subjects had a females. They determined that females had more greater maximum mean knee flexion range (92 to 105 ity than males at any age, Loudon, Goisr, and degrees) for stair ascent in comparison with taller don2S operationally defined' knee hyperextension subjects (83 to 96 degrees). Laubenthal, Smidt, and 'Ilu recurvatum) as more than 5 degtees of extension Kettlekamp33 used an electrogoniometric method to III O. Clinically, the authors had observed that not only measure knee morion in three planes (sagittal, coronal, ~.hyperextension more common in females than males, and transverse). Stair dimensions used by McFayden and t 'that the condition might be associated with func- Wintec'· were 22 cm for stair height and 28 cm for stair ~al deficits in muscle sttength, insrabiliry, and poor tread. The Rancho Los Amigos Medical Center's3S values prioceptive control of terminal knee exrension, The for knee motion in gait are presented in Table 9-5 because these values are used as norms by many physical Ors cautioned that the female athlete with hyperex- therapists. However, specific information about the ed knees may be at risk for anterior cruciare ligament population from which the values were derived was not .H. Hall and colleagues26 found that 10 female supplied by the authors. ie~ts diagnosed with hypermobility syndrome had rations in proprioceptive acuiry at the knee compared Oberg, Karsznia, and Oberg)6 used c1ecttogoniome- han age-matched and gender-matched control group. ters to measure knee joint motion in midstance and swing ames and Parker27 studied knee flexion ROM in 80 phases of gait in 233 healthy males and females aged 10 \"'and women who were aged 70 years ro older than to 79 years. Only minor changes were attributable to ears, Women in this group had greater ROM in both age, and the authors determined that an increase in knee -e and passive knee flexion than men. Overall knee angle of abour 0.5 degrees per decade occurred at 'on values were lower than expected for both midstance and a decrease of 0.5 to 0.8 degrees in knee ers, possibly owing to the fact that the subjects were angle in swing phase. Jured in the prone position, where the two-joint s femoris muscle may have limited the ROM, In X.ast to the findings of James and Parker,27 Escalante oworkers24 found that female subjects had reduced

226 PART III LOWER·EXTREMITY TESTING r''.o-v (8.4) 10-100.0 (8.2) 20-100.0 ~~r~lFfhu~lItJP_J< . 0-93.0 (10.3) \",,0--106.0 (93) .&;1('0-117.0 (13.1) (SO) = Standard deviation . .. Sample consisted of a control group of 11 healthy subjects (6 males and 5 females) with a mean age of 53 years. t Sample consisted of 15 healthy women aged 19 to 26 years. *Sample consisted of 30 healthy men with a mean age of 25 years. § Sample consisted of 1 subject measured during eight trials. , \"Large Sample'\" data collected over a number of years. FIGURE 9-5 Rising from a chair requires a mean knee flexion of 90.1 degrees. 3o FIGURE 9-4 Descending stairs requires between 86.930 and 10731 degrees of knee flexion depending on the stair dimen- ,,i sions. , i

CHAPTER 9 THE KNEE 227 socks requires approximately 117 Reliability and Validity Reliability studies of active and passive range of knee motion have been conducted in healthy subjects37- 1l and in patient popu!ations:'2-45 Boone and associates,J? in a study in which four testers using universal goniometers measured active knee flexion and extension ROM at four weekly sessions, found that intratester reliability was higher than intertester reliability. The roral intratesrer SD for measurements at the knee was 4 degrees, whereas the intertester SD was 5.9 degrees. The authors recom- mended that when more than one tester measures the range of knee motion, changes in ROM should exceed 6 degrees ro show that a real change has occurred. Gogia and colleagues38 measured knee joint angles between 0 and 120 degrees of flexion. These measure- ments were immediately followed by radiographs. Interrester reliabiliry was high (Table 9-6). The intraclass correlation coefficients (ICC) for validity also was high, 0.99. The authors concluded that the knee angle meas- urements taken with a universal goniometer were both reliable and valid. Rheault and coworkers39 investigated intencster relia- bility and concurrent validity of a universal goniometer and a fluid-based goniometer for measurements of active knee flexion. These investigators found good interrester teliabiliry fOt the universal goniometer (Table 9-6), and the fluid-based goniometer (r = 0.83). However, signifi- cant differences were found between the instruments. Therefore, the authors concluded that although the TABLE 9-6 Intratester and Intertester Reliability: Knee Range of Motion Measured with a Universal Goniometer ,~ROM = Active range of motion; ICC = intraclass correlation coefficient; PROM = passive range of motion; r = Pearson Product Moment Correlation Coefficient.

228 PA RT III LOWER-EXTREMITY TESTING universal and fluid-based goniometers each appeared to t.\".;(Cfl:-;I()1l fllC;lSllITl11clll\", hcc Tlhle ~-6i. Illtcrtcst't.'r rc:!ia. have good reliability and validity, they should not be used hiliry W;1;-. 1101 impn)\\-'t.·d by n:pt.·;ucd ltk·:ISUn.:l1kIHS. hut intetchangeably in the clinical setting. Battholomy, \\\\\";b illlpro\"l'li when (.:~tl,.'r~ lI~cd Ihe <\";11111,.' p;Hieflt posi. Chandler, and Kaplan'\" had similar findings. These tiolling. Inrerdt.\"vin· rdiability was high for :111 r1lC.lsure_ authors compared measurements of passive knee flexion Ill.... IH~. ~cidll,\"T th .. L\"()I11P()~ili()Jl of the 1II1i\\\"Crsal ROM taken with a universal goniometer with measure- goniollleter 1flll't:d or pl:l~tic) nor rhe Sill' (large or small) menrs taken with a fluid goniometer and an Optotrak Iud J signific;11l1 dfcl\"r 011 lhe 11l(':ISUl\"ellll'llts\" motion analysis system. Subjects for the study were 80 ;\\-lollillgcr :1lld Stdfall~.! colk\\.·{('d iIHr:w:ster reliahility individuals aged 22 to 43 years. All subjects were tested d;H:l Oil 1llC\":lSlIrt.·fllcnt of kncL' l::-:ICllSioll made hy two in the prone position, and a hand-held dynamometer was resrl'f~ u:-ing:\\ lIlJivL'r.. al goniolllder. ICes for knte l.'xtcn- used to apply 10 pounds of force on the distal tibia. siOl\\ r\",'pl':Hl't1 1l11.'.hurl,.'llh.:nrs \\\\\"cr\\,: high (see Tahlt 9-6), Individually, the universal goniometer and the fluid wi rh ditt\"crL'llI..·t.'S bd\\\\'ccll r<.:'f)(·:Ht.·d mea su l'eJl1ClHS a\\'crag. goniometer were found to be reliable instruments for illg 1 degree. P:llld:-\"a and colk';lgllCS'I\"1 studied inrr;Hcsrer measuring knee flexion passive ROM_ ICCs for the and inrert\"esra rt.'liabiliry ot passi\\'l' kll .. \\,: l'Xle!1sinll Illcas- univelSal goniometer were 0.97 and for the fluid lIf(.:'Ill.. IHS in 150 ....hildrl·ll agl.'d I w 20 yt';1rS, whn h~d a goniometer 0.98. However, there were significant differ- diagnosis of Duch(·nn...· Illuscular dystrophy. Inrratcster ences among the three devices used, and the authors rdi;lhilit:-\" wirh liSt' (If rhl' universal goniollldcr was caution that these instruments should not be used inter- high, but illlt'l\"It:Srcr rt.:liabiliry \\\\'~IS onl}' fair (st.·l· Table changeably. 9-61. Enwemeka41 compared the measurements of six knee \\V;\\IKiIIS and associ;!rcs\"l; (Hllpared passivl' ROM joint positions (0, 15, 30, 45, 60, and 90 degrees) taken lJ1t::lSur.. m.. nrs of rhe klll.·l'S of 43 parit'lHs Ill;ldc by 14 with a universal goniometer with bone angle measure- ph~· .. it,.':ll thL'r:lrisr~ \\\\'ho ll~(\"d a universal gCHliolllt·tt:r and ments provided by radiogra phs. The measurements were \\·isuall,.·:-tilllat.. s. Thes aurhor:-. found that illlr:lfl'S[Cr reii- taken on 10 healthy adult volunteers (four women and .lhiliry wirh tht' univ rsal goniometer \\\\'a:- high for both six men) between 21 and 35 years of age. The mean krH:t· fll'xio!l JIll.! knce ('sr(.'IlSioll. Illt't:rrCSl'tl' ftklbiliry for differences ranged from 0.52 to 3.81 degrees between gOlllol1l('rri.... lllt\\lsurCIllClHs also \\\\,;ts high lor knce flexion goniometric and radiographic measurements taken bur only gond for k!lCt· <:.::-:rl·nsio!l (Sl'C Table 9-6), I between 30 and 90 degtees of flexion. However, mean Inrr:H .. srt'f ;llld ilHlTlcStt.·r reliahility \\\\'t.'f(' lo\\\\'er for visual I mettic and radiographic measurements of the angles ;llIdlOl'S suggestnl that rhC'f;lpisrs should nor substitute differences were higher (4.59 degrees) between gonio- cst i1ll:1 I ion rh;1 n for gon iOIlll.'rric l1lC:l$U relllen t\" The ,! Rothstein, Miller, and Roc[[ger42 investigated intra- assessing a paricnr\"s r:lllgc of kllt~l' motion hcclUse of the f between 0 and 15 degrees. \\'isual csrim:Ht's for goniomerric IllClsurcmenrs when tester, intertester, and inrerdevicc reliability in a study :lddirioll::d error t1wl is imrodllced with uSt.; of visu:d csri- I involving 24 patients referred for physical therapy. mation, :\\ parient's diagnosis did nor app ...·\"r to affcl.:[ rcli· I [ntratester reliability for passive ROM measurements for ability. excepr in rh...· <:ase of heIO\\\\\"·KIl('t.' amputees. I flexion and extension was high. Intenesrer reliability also HOW...,\\·tT. rhe small number of ;lInpurt'cs in the parient was high among the 12 testers for passive ROM meas- samplt: prevented rhe :lLlthors t'rOll1 lll:lking any conclu· urements for flexion, but was relatively poor for knee sions about fl:liability ill this qrpe ot parienr. t \"1 I 1 , ~.. ,

CHAPTER 9 THE KNEE 229 of Motion Testing Procedures: Knee

PART III LOWER-EXTREMITY TESTING FLEXION knec into flexion (Fig. 9-9). Stabilize the thigh to prevent further motion and guide the lower leg into knee flexion. Motion OCCUtS In the sagittal plane around a medial- The end of the range of knee flexion occurs when resist_ lateral axis. The range of motion for flexion ranges from ance is felt and attempts to overcome rhe resistance cause 132.0 degrees (Roach and Miles\") to 142.5 degrees additional hip flexion. (Boone and Azen lO) to 150.0 degrees (AMA'). Please refer to Tables 9-1 through 9-4 for additional ROM Normal End-feel information. Usually, the end-feel is soft because of contact between Testing Position the muscle bulk of the posterior calf and the thigh or Place rhe subject supine, with the knee in extension. between the heel and the buttocks. The end-feel may be Position the hip in 0 degrees of extension, abduction, and firm because of tension in the vastus medialis, vasrus adduction. Place a towel roll under the ankle to allow the latetalis, and vastus intermedialis muscles. knee to extend as much as possible. Goniometer Alignment Stabilization Sec Figures 9-10 and 9-11. Stabilize the femur to prevent rotation, abduction, and adduction of the hip. 1. Center rhe fulcrum of the goniometer over the lateral epicondyle of the femur. Testing Motion Hold the subject's ankle in one hand and move the poste- 2. Align thc proximal arm with the lateral midline of rior thigh with the other hand. Move the subject's thigh to approximately 90 degrees of hip flexion and move the the femur, using the greater trochanter for refer~ cnec. 3. Align the distal arm with the lateral midline of the fibula, using the lateral malleolus and fibular head for reference. FIGURE 9-9 The right lower extremity at the end of knee flexion ROM. The examiner uses one hand to move the subject's thigh to approximately 90 degrees of hip flexion and then stabilizes the femur to prevent further flexion. The examiner's other hand guides the subject's lower leg through full knee flex- ion ROM.

CHAPTER 9 THE KNEE 231 FIGURE 9-10 In the starting position for measuring knee flexion ROM) the subject is supine with the upper thigh exposed so that the greater trochanter can be visualized and palpated. The examiner either kneels or sits on a s[Ool to align and read the goniometer at eye level. FIGURE 9-11 At the end of the knee flexion ROM, the examiner uses onc hand to maintain knee flex- ion and also to keep the distal arm of the goniometer aligned with the lateral midline of the leg.

232 PA RTill LOWER·EXTREMITY TESTING EXTENSION Goniometer Alignment Ntorion occurs in the sagittal plane around a medial· I. Center the fulcrulll of rhe goniollletc:r Over th lateral axis. Extension is nm usually measured and recorded because it is a remrn to the starting position lateral epicondyle of the felllur. e from the end of the knee flexion ROM. 2. Alig~ the proximal arlll with the !a tera I midline of Normal End-feel the femur, using the greater trOdl<.lIHer for rder. The end-feel is fitm because of tension in the posterior joinr capsulc, the oblique and arcuate poplitealligamenrs, ence. the collateral ligaments, and the anterior and posterior cruciarc ligaments. J. Align the distal arm with the btl'rat midline of the-; fibula, using the lateral malleolus anJ fibular head' for referencc. Muscle length Testing Procedures: \\'Vhen the rcCtus fCllloris musclc COrHr:lCts, it flexes the' Knee hip and extends the knee. If rhe rC([lIS fcmoris is shorr RECTUS FEMORIS: ELY TEST . knee flexion is limited whcn rhe hip is Ill<limained in ~ The rectus femoris is onc of the four muscles that make up the muscle group called the quadriceps femoris. The neutral position. If knce flexion is limited when rhe hip is rectus femoris is the only one of the four muscles that in a flexed position, rhe limitatioll is nor owing to a short crosses both the hip and the knee joints. The muscle rcnus femoris rnus:cle but to ~lbn()rJ1lalities of joint struc. arises proximally from (wo tendons: an anterior tcndon turcs or shorr onc~ioint knee extensor Illuscles. from the anterior inferior iliac spine, and a posterior tendon from a groove superior to the brim of the acetab- Starting Position ulum. Distally, the muscle a[[aches to the base of the patella by way of the thick, flat quadriceps tendon and Place the subject prone, \\\\Iirh both feet off the end of the attaches to the tibial tuberosity by way of the patellar ~xaJ1liJ1iJ1g tab~c: Extend the knees and position the hips ligamenr (Fig. 9-12). 1I1 0 degrees or Hexion, extension, abduction, adduction, and roration (Fig. 9-13), Stabilization Stabilize the hip to maintain the ncutral position. Do not allow the hip to flcx.

CHAPTER 9 THE KNEE 233 Anterior inferior iliac spine - + - Rectus femoris h7/1itt-'I-/--- Patella Tibial tuberosity ---\\-+'~Y Patellar ligament AGURE 9-12 An anterior view of the left lower extremity showing the attachments of the rectus femoris muscle. FIGURE' 9-13 The subject is shown in the prone starting position fot testing the length of the tectus femoris muscle. Ideally, the feet should be extended over the edge of the table.

234 PART III LOWER-EXTREMITY TESTING FIGURE 9-14 A lateral view of the subject at the end of the tes~ing motion for the length of the left rectus femoris muscle. FIGURE 9-15 A lateral view of the left rectuS femoris muscle being stretched over the hip and knee joints at the end of the resting morion.

CfiAPTER 9 THE KNEE 235 lining the lower leg off the rable. The Goniometer Alignment occurs when resistance is felt from See Figure 9-16. anterior thigh and further knee flexion to flex. If the knee can be flexed to at least 1. Center the fulcrum of rhe goniometer over rhe lateral epicondyle of rhe femur. the hip in the neutral position, the length f,rno\"i, is normal (Figs. 9-14 and 9-15). 2. Align the proximal arm with the lateral midline of the femur, using the greater trochanter as a refer- ence. 3. Align the distal arm with the lateral midline of the fibula, using the lateral malleolus and the fibular head for reference. FIGURE 9-16 Goniometer alignment for measuring the position of the knee. '.'.

';i 236 PA RTill LOWER· EXTREMITY TESTING supracondylar linc) and rhe latcral intermuscular septurn. Z.u.I • •• The disral attachments of the biceps femoris are On the :.: The hamstring muscles are composed of the semirendi- head of rhe fibula, wirh a small porrion attaching to the nosus) semimembranosus and biceps femoris. The semi- tiL tendinosus and semimembranosus as well as the long lateral tibial condyle and the lateral collateral ligament head of rhe biceps femoris cross both the hip and rhe knee ~ joints. The proximal arrachment of the semitendinosus is (sec Fig. 9-17A). on the ischial ruberosity and the distal attachment is on ··\"\"·'/·w:0::t,l,·;: rhe proximal aspect of the medial sutface of the tibia (Fig. When the hamstring muscles contract, they extend the 9-17A). The proximal attachment of rhe semimembra- uti nosus is on the ischial tuberosity and rhe distal atrach- hip and flex rhe knee. In the following test, the hip is menr is on the medial aspect of rhe medial tibial condyle. .'. dj; (Fig. 9-17B) The biceps femoris muscle atises from two maintained in 90 degrees of flexion while the knee is z'o heads; rhe long head atraches to the ischial tuberosity and extended to determine whether the muscles arc of normal j$;~:' ';.xii rhe sacrotuberous ligament, whereas rhe shorr head length. If the hamstrings are shorr, the muscles limit knee ~.o.. attaches along rhe lateral lip linear aspera, the lateral extension ROM when the hip is positioned at 90 degrees .~. ::0:;.'. <; 0,;\" ~~ of f l e x i o n . , ~. ~~ Gajdosik and associares,46 in a study of 30 healthy\"'.: 1u.-I,' :I:~ males aged 18 to 40 years found a mean value of 3L:jZ'ld. ,;;,\"\"\"'<,1,<, ~. degrees (SD = 7.5) for knee flexion during this tesr.'i;::;':; Values for knee flexion ranged from 17 to 45 degrees.;4L:'.:·j Examiners reported that end-feel was firm and easily::;;J' ',. identified. .~ Ischial Ischial ,\",,,J+-l-lf-- tUberosity ';::\".J-I-++- luberosity Semilendinosus ++-+- Biceps femons (tong head) -+~!--- Semimembranosus Semimembranosus - - - 4 - Biceps lemons (short head) 1'1-1-- Head of />rl-- Head of Tibia ----+-'
_ fibula Tibia ----4-_1_ fibula AB FIGURE 9-17 (A). A posterior view of the thigh showing the attachments of the semitendinosus and the biceps femoris muscles. (8). A posterior view of the thigh showing the attachments of the semimembra- nosus muscle which lies under the rwo hamstring muscles shown in Figure 9-17A.

CHAPTER 9 THE KNEE 237 '. Starting Position \"\"~~sition the subject supine with the hip on the side being i;';ed in 90 degrees of flexion and 0 degrees of abduc- tion, adduction, and rotation (Fig, 9-18), Initially, the knee being tested is allowed to relax in flexion, The lower ixtremity that is not being tesred rests on the examining , ,table with the knee fully extended and the hip in 0 0' degrees of flexion, extension, abduction, adduction) and rotation. ,.. S, t.\"a,\"-b\" i.l.ization ,~~ \"Stabilize the femur to prevent rotation, abduction, and adduction at the hip and to maimain the hip in 90 degrees of flexion, FIGURE 9-18 The starting position for measuring the length of the hamstring muscles.

238 PA RT III LOWER-EXTREMITY TESTING Testing Motion Normal End-feel Extend the knee to the end of the ROM. The end of the The end-feel is firm owing to tension in the semimem_ testing motion occurs when resistance is felt from tension branosus, semitendinosus, and biceps femoris muscles. in the posterior thigh and furrher knee extension causes the hip to move roward extension (Figs. 9-19 and 9-20). FIGURE 9-19 The end of the testing motion for the length of the right hamstring muscles. ~. FIGURE 9-20 A lateral view of the right lower extremity shows the hamstring muscles being stretched over the hip and knee joints at the end of the testing motion.

Goniometer Alignment C HAP T ER 9 THE KNEE 239 See Figure 9-21. 2. Align the proximal arm with the lateral midline of 1. Center the fulcrum of the goniometer over the the femur, using the greater trochanter for a refer- lateral epicondyle of the femur. ence. 3. Align the distal atm with the lateral midline of the fibula, using the lateral malleolus and fibular head for reference. FIGURE 9-21 Goniometer alignment for measuring knee position.

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RE ;lnd I\\.;tpl.m. SF:: V;llidiryan variables. Phys Ther 73:437, 1993. (If t'lIlid t:.(;lli~lllll·ltr ll1Cl'tlTl'llle1H-; ot klll-e fh:xion. [AbsIr.1 23. Steultjens, MPM, et al: Range of motion and disability in parients Tlwr SO:S46. 1.(100. with osteoarthritis of the knee or hip. Rheumatology 39:955, cs:41. EI\\Wl·nl~-LI. R;adlo!'.r.lphi( n;riiicHi\"n 2000. 24. Escalante, A, et al: Determin::mts of hip and knee flexion range: ~(:l1ld 1 Rdl;lbll.\\kd IS:·J-. IllSi>. 42. Rl'llh.,!~·IIl . .1\\1, \\ldlvr, P.l. :l1ld ROi:II~l'r. RF: Results from the San Antonio l.ongitudinal Study of (\\ging_ 11'- 111 ,I ,Jini..·.ll ~l·fllllt.:. Ph\\\", Thn (•.l; 1611. 19SJ_ Arthritis Care Res 12:8, 1999. 43. \\X'.Hklll:o>• .\\1:\\. rt :11: Itdi.ll;tlit\\, oi !.:I'niomr.:rri,: Il\\{';\\$urcmen \"'hILl! nlil11.\\ll'~ oi knn' r;Jl1~l· III 1\\101lt'l1 ohfained in a ~.. s:~1·llillt.:. Pin·., Till·f 71 :\\Jtl. I'J91_ 44. 1',1Ild~·,I. l·f ,11: Ih·li;lhJ1il\\\" 01 !:0l1I0IllL·lri... lllcasureme p.ltll-;ll\" \\\\-ith l)UCht-lllll' nHl~~lll.lr dY~lrlll'hy. i)hrs Ther 65: 19S5. r.:.45. Iki~'l\\n ColIllls IF ,lIhl Holllil\" II: .\\Iusl,:k illllrlOIl ;IS predll:H',r, 01 iUlk'littll 111 (,Ider S():_':i6.2011\\), 46. (;.ljdo~ik l'r ~t1: C:omp;lnslIll lli four ,11111(.;,11 tc~l~ illl.:: 1:.lImlrill~ lllllsck· kll~l1l. I Orllll.lp ~rO(( I'hys 1~'J3_ ~ •.

yThe Ankle and Foot _ Structure and Function Talocrural Joint Proximal and Distal TIbiofibular Joints Anatomy Anatomy The ralocrural joint comprises the articulations between the talus and the distal tibia and fibula. Proximally, the The proximal tibiofibular joint is formed by a slightly joint is formed by the concave surfaces of the distal tibia cpnvex tibial facet and a slightly concave fibular facet and the tibial and fibular malleoli. Distally, the joint .arid is surrounded by a joint capsule that is reinforced by surface is the convex dome of the talus. The joint capsule \",nterior and posterior ligaments. The distal tibiofibular is thin and weak anteriorly and posteriorly, and rhe joint loint is formed by a fibrous union between a concave is reinforced by lareral and medial ligaments. Anterior Jacet on the lateral aspect of the distal tibia and a convex and posterior ralofibular ligaments and the calcaneofibu- \"~cet on the distal fibula. (Fig. 10-IA) Both joints are lar ligament provide lateral suPPOrt for rhe capsule and s'upported by the interosseous membrane, which is joint (Fig. 10-2A and B). The deltoid ligament provides ,located between the tibia and the fibula (Fig. 10-lB) The medial support (Fig. 10-3). Wstal joint does not have a joint capsule but is supported Osteokinematics or anterior and p~>Sterior ligaments and the ccural The taloccural joint is a synovial hinge joint with 1 ,·~terosseous tibiofibular ligament. (Fig. 10-IC). degree of freedom. The motions available are dorsiflex- ion and plantarflexion. These motions occur around an Qsteokinematics oblique axis and thus do nor occur purely in the sagittal plane. The motions cross three planes and therefore arc The proximal and distal tibiofibular joints are anatomi- considered to be triplanar. Dorsiflexion of the ankle :'c'3l1y distinct from the taloccural joint but function to brings the foot up and slightly Iareral, whereas plan- tarflexion brings the foot down and slightly medial. The jerve the ankle. The proximal joint is a plane synovial ankle is considered to be in the O-degree neutral position .)qint that allows a small amount of superior and inferior when the foot is at a right angle to the tibia. /,s.liding of the fibula on the tibia and a slight amount of J~tation. The distal joint is a syndesmosis, or fibrous Arthrokinematics ~~ion, but it also allows a small amount of motion. In dorsiflexion in the non-weight-bearing position, the ralus moves posteriorly. In plantarflexion, rhe talus moves anteriorly. In dorsiflexion, in the weighr-bearing position, the tibia moves anteriorly. In planrarflcxion, rhe tibia moves posteriorly. Capsular Pattern The pattern is a greater limitation in plamarflexion than in dorsiflexion. 241 ---- /,

242 PA RT III LOWER·EXTREMITY TESTING ligament Posterior ligament of fibular head Anterior ligament of fibular head I ~+-+- Interosseous membrane I Fibula Tibia Distal tibiofibular Anterior II tibiofibular ....joint ----1-.1 ligament II _/' Posterior tibiofibular ~r-...J.~~~r- ligament FIGURE 10-1 (A) The anterior aspect of the proximal and distal tibiofibular joints of a right lower extremity. (B) The anterior tibiofibular ligaments and the interosseous membrane. (C) The posterior aspect of the tibiofibular joints and the posterior tibiofibular ligaments of a right lower extremity. +Fibula _ _ -1-_Tibia Tibial---+ Fibula TatoCfural Posterior Talus joint Talus tibiofibular·--I- Posterior talolibutar ligament .....:::::----r-- Talocrural ligament ~~~;;:\"..: _..J~.... joint Calcaneofibular ligament ifI\"'''--c=l..-- Posterior talofibular ligament Calcaneolib_u~l:ar~_-, ligament Calcaneus 5th metatarsal +--- Calcaneus A Cuboid B FIGURE 10-2 (A) A lateral view of a left talocrural joint with the anterior and posterior talofibular liga- ments and thecalcaneofibular ligament (B) A posterior view of a left talocrural joint shows the posterior talofibular ligament and the calcaneofibular ligament.

CHAPTER 10 THE ANKLE AND FOOT 243 Posterior tlbiotalar Deltoid Tibiocalcaneal ligament Anterior tibiolalar } Tibionavicular Navicular FIGURE 10-3 The deltoid Iigamenc in 3 medial view of 3 left ralocrural joint. ;Surbt,llar Joint Osteokinematics c\"The subtalar (talocalcaneal) joim is composed of three The motions permitted at the joinr arc inversion and ,__:.separare plane articulations: the posterior, anterior, and eversion, which occur around an oblique axis. These cmiddle aniculations between the talus and the calcaneus. motions arc composite motions consisting of abduction- adduction, flexion~extension, and supination~pronation. 1 ->Thc posterior articulation, which is the largest, includes a In non-weight-bearing inversion, the calcaneus adducts around an anterior-posterior axis, supinarcs around a concave facet on the inferior surface of the talus and a longitudinal axis, and plantar flexes around a medial· [convex facet on the body of the calcaneus. The amerior lateral axis. In eversion, the calcaneus abducts, pronates, 2~nd middle articulations are formed by rwo convex facets and dorsi flexes. ton the talus and twO concave facets on the calcaneus. The 'i'merior and middle articulations share a joim capsule Arthrokinematics ~tjyirh the talonavicular joim; the posterior articulation has )s own capsule. The subtalar joim is reinforced by ame- The alternating convex and concave facets limit mobility ';tior, posterior, lateral, and medial talocalcanealligamems and create a twisting motion of the calcaneus on the and the interosseus talocalcaneal ligamem. (Figs. 10-4 ~nd 10-5). Talus Talus Subtalar Subtalar joint Posterior joint talocaneal ,I ligament Lalerallalocalcaneal ligament ) /JS Calcaneus --_.-<\"~' Calcaneus Medial talocalcaneal ligament ]jGURE 10-4. The imerosseus talocaleaneal and lateral talo- FIGURE 10-5 The medial and posterior talocaleaneal liga- :calcancalligamencs in a lateral view of a Ich subtalar joinc. ments in a medial view of a left subralar joint.