Factors Related to Extension Lag at the Knee Joint

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1 /82/0304-Ol78$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Factors Related to Extension Lag at the Knee Joint ROBERT 6. SPRAGUE, PhD, RPT* Twenty patients were examined in an investigation of the relationships between extension lag at the knee and other measures taken from the injured and uninjured extremity. The results of the study show: 1) there were no significant correlations between extension lag and the depth of squat, the extension force or force, the circumference at the joint line or the circumference 5 and 15 centimeters cephalad to the patella pole, and active or passive knee ; 2) that the mean for force was greater than the mean for extension force in the injured extremity, and there was no difference between the means for and extension force in the uninjured extremity; and 3) that the means of the measures for active and passive, force, and circumference measures of the thigh taken from a group of patients who had stiff rotational movements at the tibiofemoral joint.were different from the means of the same measures taken from a group of patients who had normal rotational movements. There is limited evidence to suggest that weakness of the quadriceps muscle may be a factor in extension lag at the knee, but the support for this conclusion is based on comparison between groups of patients and not from the correlations between other variables and extension lag. For future studies, it is recommended that an attempt be made to secure patients with extension lags greater than 3Oin an effort to improve the prospect of detecting any relationships. Extension lag (EL) is seen in posttraumatic knees as a consequence of either injury or surgery, and the elimination of EL is a treatment goal in the physical therapy program. EL is defined as a condition in which the active range of the knee extension is less than the passive range of knee extension. The term EL is used in preference to quadriceps lag because it is suggested that there may be other factors involved in the condition besides proper functioning of the quadricep muscles. It is possible that EL may be caused by muscular weakness,~ , l5 joint stiffnes~,~. 7. and pain.', 37 PURPOSESOFTHE STUDY 16 joint di~tension,~. The purposes of this study are to investigate the relationship between EL at the knee and 1) isometric muscle force of knee extension and knee ; 2) active range of knee and pain; 3) knee joint circumference; 4) thigh circumferences; 5) passive movements and pain of 'From the South Australian Institute of Technology. Adelaide, South Australia. and lthaca College. Ithaca. NY the tibiofemoral articulation; 6) passive movements, pain, and crepitus of the patellofemoral articulation; and 7) passive movements and pain of the superior tibiofibular articulation, and also to identify the factors which appear to be most related to EL and to suggest methods of treatment. METHOD Each of 20 patients who were being treated for knee disabilities were assessed objectively and subjectively. Patients ranged in age between 18 and 40 years, and there was no attempt to select patients with a particular disability. If the patient had an EL detected by the staff therapists, had greater than 60' of knee, and near normal passive knee extession, he was admitted to the study. The bilateral objective assessment included: a squat movement to the joint where discomfort was first noted in the lower extremity; isometric force for knee extension and measured at 30" in a sitting position using a salter pocket balance; circumferences measures at the joint line, 5 centimeters cephalad to the patella pole,

2 JOSPT Spring 1982 EXTENSI ON LAG 179 and 15 centimeters cephalad to the patella pole; and active and passive taken in the prone position. To measure EL the examiner placed a clenched fist under the patient's heel so that the extremity was clear of the table. The patient was then asked to tighten the quadriceps muscle by pushing his knee down toward the table. With his other hand, the examiner palpated the quadriceps tendon at the superior pole of the patella to ensure that the muscle was exerting a force. The patient was then asked to keep his knee straight, and simultaneously lift his heel off the examiner's fist. An EL was detected when the knee did not remain fully extended as the patient's heel was lifted off the examiner's fist; thus, if there was an EL, the knee flexed as the leg was lifted and the degree of this movement was recorded as EL. The amount of movement was estimated by the examiner without the use of a goniometer, although a goniometer was used in trial measurements to estimate 5" EL which was used in the study as a base line. It is important for the examiner to be positioned at eye level with the patient's lower extremity so that he can observe any lower extremity movement in the sagittal plane. A total of 194 tests of passive movements, pain, and crepitus were performed at the tibiofemoral, patellofemoral, or superior tibiofibular joints. Passive movement tests were administered as described by Maitland (1 4). Movement was recorded as more than normal, normal, less than normal, or stiff. Pain was recorded as no pain with overpressure, pain with overpressure, or pain without overpressure. Crepitus was recorded as no crepitus, crepitus with compression, or crepitus without compression. The subjective assessment of each patient included a series of 21 predetermined questions aimed at clarifying the extent of their disability, the irritability of the joint(s), and the past history. RESULTS The distribution of measures of extension lag (EL) was as follows: EL Frequency 2 O 9 3 O 5 4" 3 6" 2 7" 1 There were no statistically significant correlations between EL and the variables measured. However, there were differences between groups which provided some interesting findings. Estimates of EL recorded by the author and estimates of EL recorded independently by a staff physiotherapist who was treating the patient on a clinic schedule were as follows: Patient number Author's Staff's estimate estimate 6" 5" 3" 3" 3O 3O 3 O 3" 6 O 6' 2O 2 O Differences Between Injured and Uninjured Knees seven variables taken from the injured extremity and the measures of the same seven variables taken from the uninjured extremity were calculated. For measures of extension force, force, circumference at the joint line, circumference 15 centimeters cephalad to the patella pole, active, and passive, the differences were significantly different from zero at the 0.05 level. For measures of circumference 5 centimeters cephalad to the patella pole, there was not a significant difference at the 0.05 level. These data are presented in Table 1. ~ifferenck Between Means of Normal and Stiff Movements All measures were taken from the injured extremity. Extension, medial and lateral rotation at 10", and medial and lateral rotation at 90' movements of the tibiofemoral joint, and inferior medial movements of the patellofemoral joint were used to differentiate the normals from the stiff. There were 54 comparisons calculated using the same seven variables listed under the purposes of the study, plus the EL variable. The seven differences which were significantly different from zero are shown in Table 2. Differences Between Extension and Flexion Force extension force taken from the injured extremity

3 180 SPRAGUE JOSPT Vol. 3, No. 4 TABLE 1 Tests of mean difference between measures taken from uninjured extremity and same measures taken from injured extremity (N = 20) Variable Mean difference 95% confidence interval Significant Extension force (injured less) 6.15 kg Flexion force (injured less) 4.00 kg Circumference at joint line (injured cm greater) Circumference 5 cm above patella (injured 0.31 cm less) Circumference 15 cm above patella (in cm jured less) Active (injured greater distance) cm Passive (injured greater distance) cm TABLE 2 T-Test of difference between means of measures taken from normal and stiff movements of the injured extremity Active Passive Variable Circumference 5 cm above patella Circumference 15 cm above patella Flexion force Active Passive Movement used to differentiate normal and stiff Medial rotation at Medial rotation at and the measures of force taken from the injured extremity was significantly different from zero. extension force taken from the uninjured extremity and the measures of force taken from the uninjured extremity was not significantly different from zero. These data are presented in Table 3. Crepitus, Patellofemoral, and Superior Tibiofibular Joints Measures of crepitus and other measures taken from the patellofemoral and superior tibiofibular joints did not show any particular patterns. Therefore, there were no relationships between these measures and other measures in the study. DISCUSSION Although there were no significant correlations between EL and the variables measured which Means (N) = normal (S) = stiff Two-tailed probability (N) cm 0.01 (S) cm (N) cm 0.01 (S) cm (N) cm 0.04 (S) cm (N) cm 0.01 (S) cm (N) kg 0.01 (S) 7.15 kg (N) cm 0.01 (s) cin (N) cm 0.01 (S) cm TABLE 3 T-Test of mean difference between measures of and extension force for the injured and uninjured extremity (N = 20) Two- Mean Mean T- tailed Variable (kg) difference Value probability Extension force 5.90 (injured) Flexion force (injured) Extension force (uninjured) Flexion force (uninjured) would permit prediction of EL from another variable, the results of this study do point to some factors which may be most related to EL. These results, obtained by comparisons of groups, suggest that certain characteristics appear in groups

4 JOSPT Spring 1982 EXTENSION LAG 181 of patients who have had a knee disability and that the knee involved also exhibited an EL. Based on these comparisons between groups, it seems reasonable to conclude that, in groups of patients who have EL, one may also find general quadriceps weakness, joint stiffness, and joint distension. Whatever factors contributed directly to the EL cannot be determined by this study because of the lack of significant correlations between EL and other variables. However, it is suggested that the relatively small degree of EL found in most patients (1 4 of 20 had 3" or less EL) may have masked the key factorb) related to EL because whatever factor(s) causing EL may have been largely corrected by nature and/or treatment before the measurements were taken. There was a hint of a relationship between some of the variables and EL when the measures from the patients with the larger ELs (greater than 3") appeared on the scattergram. However, this hint of a relationship completely disappeared when the measures from the patients with the smaller ELs appeared on the scattergram. Therefore, it is recommended that in any further studies an attempt be made to secure patients with larger ELs. The review of literature suggests that EL may be related to muscle weakness, joint stiffness, joint distension, and pain. In general, this study suggests that the first three factors may, in some manner, be related to EL, and therefore, the findings in this study agree in part with the literature. There was no attempt in this study to analyze the loss of mechanical advantage, nor was there any attempt in this study to measure reflex inhibition or stimulation of muscles. Therefore, it would be inappropriate to comment on these two factors as they may relate to EL. CONCLUSIONS Twenty patients were examined in an investigation into the relationships between EL at the knee and other measures taken from the injured and uninjured extremity. The results of the study show there were no significant correlations between EL and the variables measured. There is limited evidence to suggest that weakness of the quadriceps muscle may be a factor in EL. There was insufficient evidence to permit prediction of EL from other variables. Since there was no relationship demonstrated by correlations, there are no specific recommendations regarding the treatment of patients with EL. However, since it is suggested in the literature that muscle weakness, joint stiffness, joint distension, and pain may be the causes of EL, it seems appropriate to treat these problems. Subjective and objective assessment of the individual patient's problem should be helpful in determining which of these factors deserves attention. For weakness, terminal extension exercises at the end of the functional range against gravity or in the gravity-reduced position are recommended. For joint stiffness, mobilization of the patellofemoral, superior tibiofibular, or tibiofemoral joint may be done to increase physiological or accessory movements. The terminal extension exercises done with an intermittent hold and relax may augment the "muscle pump" and reduce joint distension. For pain, modalities may be beneficial for treating pain caused by chemicals, and mobilization may be beneficial for treating pain caused by mechanical factors. Continuous subjective and objective assessment of the patient's response to treatment will be most helpful in determining efficacy of the treatment chosen. Special thanks to Robert E. Hall, Lecturer. Department of Mathematics, and Patricia H. Trott, Lecturer, School of Physiotherapy, South Australian Institute of Technology. REFERENCES 1. Basmajian JV: Reeducation of vastus medialis: a misconception. Arch Phys Med Rehabil51: , Basmajian JV: Integrated actions of the four heads of quadriceps femoris: an electromyographic study. Anat Rec 172:15-19, Camp VA: Synovectomy of the knee in rheumatoid arthritis. Ann Rheum Dls 31 : , Campbell D, Glenn W: Foot-pounds of the normal knee and the rehabilitated postmeniscetomy knee. Phys Ther 59: de Andrade JR, Grant C, Dixon A: Joint distension and reflex muscle inhibition in the knee. J Bone Joint Surg 47A: , Francis R, Scott D: Hypertrophy of the vastus medialis in knee extension. Phys Ther 54: 10: Hallen L. Lindahl 0: Muscle function in knee extenion. Acta Orthop Scand 38: , Helfet A: Disorders of the knee. Philadelphia: JB Lippincott Co, Jones R: Adhesions of joints and surgery. Br Med J 1 : , Karumo I, Rehunen S, Naveri H, Alho A: Red and white muscle fibers in menisectomy patients. Ann Chir Gynaecol Fenn 66: Lieb F, Perry J: Quadriceps function. J Bone Joint Surg 50A: , Lieb F, Perry J: Quadriceps function. J Bone Joint Surg 53A: Lindahl 0, Movin A: The mechanics of extension of the knee joint. Acta Orthop Scand 38: , Maitland G: Peripheral Manipulation, Ed 2. London: Butterworths, Petersen I, Stener 8: Experimental evaluation of the hypothesis

5 182 SPRAGUE JOSPT Vol. 3, No. 4 of ligamento-muscular protective reflexes. Acta Physiol Scand 48: 51-61, Pinsky H. Olson D: The results of excision of the patella. J Am Osteopath Assoc 78: , 1978 BIBLIOGRAPHY 1. Basmajian JV: Grant's Method of Anatomy, Ed 8. Baltinfore: Williams 8 Wilkins, Cailliet R: Knee Pain and Disability. Philadelphia: FA Davis Co, Gray's Anatomy. Ed 35. London: Longman, Hallen L, Lindahl 0: The "screw-home" movement in the knee joint. Acta Orthop Scand 37:97-105, Jenkins D, lmms F. Prestidge S, Small G: Muscle stength before and after menisectomy: a comparison of methods of postoperative management. Rheumatol Phys Med 15: , Mennel J: Joint Pain. Ed 1. Boston: Little, Brown and Co, Moore R, Bullock M: A survey of recent knee injuries treated by physiotherapy. Aust J Physiother 24:69-76, Smillie I: Diseases of the Knee Joint, Ed 5. London: Churchill Livingstone. 1974

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