Osteopathic Evaluation and Treatment of the Hip & Knee

Transcription

1 Osteopathic Evaluation and Treatment of the Hip & Knee LOMA August 20, 2016 New Orleans, Louisiana Eva B. Shay, D.O. Assistant Professor, Osteopathic Principles & Practice William Carey University College of Osteopathic Medicine

2 Lower Back Pain and the Hip Restrictors Dysfunctional hip restrictors can markedly influence the low back mechanics. Fred Mitchell, Sr., D.O., estimated that the legs played a major role, as much as 50% of the time, with lower back pain. Hip restrictor imbalance is frequently a contributing factor for chronic low back pain. The legs and the lower back are both complex regions.

3 The Six Groups of Hip Restrictors and Treatment Positions Prone Position Flexors (Quads) Internal rotators External rotators Supine Position Extensors (Hamstrings) Adductors Abductors

4 Hip & Leg

5 MUSCLE ENERGY TREATMENT STEPS Position the body part to be treated at the point of initial restriction of motion (the feather edge of the restrictive barrier) Direct the patient to contract the appropriate muscle(s), in the appropriate direction(s), with the appropriate intensity and duration Ensure that your patient s counterforce equals the amount of force you apply Maintain the force until the contraction is palpated at the appropriate location (generally, 3-5 seconds) Tell the patient to stop her contraction (gently) and simultaneously match the patient s decreased force Allow the patient to relax; sense the tissue relaxation Take up the slack to the new initial barrier. This will slowly, passively lengthen the muscle(s) Repeat three to five times, or until the best possible increase in motion is obtained Retest

6 HIP RESTRICTORS treat prone Gilroy, MacPherson, Ross, editors; Atlas of Anatomy, 2nd Edition Hip Flexors Quadriceps Rectus Femoris Vastus lateralis Vastus medialis Vastus intermedius Innervation: Femoral L2-4 Hip Internal Rotators Gluteus medius Gluteus minimus Tensor fascia lata (TFL) Innervation: Superior Gluteal L5-S1 Hip External Rotators Piriformis Obturator internus Obturator externus Gemellus superior Gemellus inferior Gluteus maximus Quadratus femoris Innervation: Obturator L5-S1

7 TREATMENT OF TIGHT QUADRICEPS Physician flexes the lower leg to the barrier Patient s lower leg is placed against the physician s hand or chest/shoulder to provide counterforce Patient is asked to straighten the leg for 3 5 seconds (contracting the quads) After the patient relaxes for a short time: Physician repositions the leg to the new feather edge of the restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

8 FEMORAL EXTERNAL ROTATION SOMATIC DYSFUNCTION Diagnosis Patient s internal rotation of the thigh is restricted by tight external rotators Both legs can be tested and compared at the same time with the patient in the prone position Treatment Physician s hand is placed against the medial malleolus of the involved extremity Physician internally rotates the extremity to the feather edge of the barrier Physician s cephalad hand should be placed on the posterior pelvis to prevent rotation of the pelvis on the table to assess for proper patient s force of contraction Patient is asked to bring their ankle into the physician s hand for 3-5 seconds After the patient relaxes for a short time: Physician repositions the leg & hip to the new feather edge of the restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

9 FEMORAL INTERNAL ROTATION SOMATIC DYSFUNCTION Diagnosis Patient s external rotation of the thigh is restricted by tight internal rotators Each leg is assessed independently then the ROM is compared with the patient in the prone position Treatment Patient s involved extremity is taken to the feather edge of the restrictive barrier Physician assures patient s knee is at 90 Physician s cephalad hand should be placed on the posterior pelvis of the affected side to prevent rotation of the pelvis on the table and to assess for proper patient s force of contraction Physician s hand is at the lateral malleolus to provide a point of resistance The patient is asked to internally rotate his leg, matching the physician s counterforce for 3-5 seconds Patient relaxes After the patient relaxes for a short time: Physician repositions the leg and hip to the new feather edge of the restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

10 HIP RESTRICTORS treat supine Hip Extensors - Hamstrings Biceps femoris long head Biceps Femoris short head Semimembranosus Semitendenosus Innervation: Tibialus L2-4 Hip Adductors Adductor brevis Adductor longus Adductor magnus Gracilis Innervation: Obturator L2-4 Hip Abductors Gluteus medius Gluteus minimus Tensor fascial lata (TFL) Innervation: Superior Gluteal L5-S1 Gilroy, MacPherson, Ross, editors; Atlas of Anatomy, 2nd Edition

11 TREATMENT OF TIGHT HAMSTRINGS Patient is supine on the table Physician is on the same side of the table as the involved extremity Physician places patient s distal leg on his shoulder Physician s hands are placed just proximal to the patient s knee Patient is asked to bring his heel or ankle into the physicians shoulder and push his away by extending the hip (contracting the hamstrings) Effort is held for 3-5 seconds After the patient relaxes for a short time: Physician repositions the patient to the new feather edge of the restrictive barriers (hip flexion & knee extension) Cycle is repeated 2-4 times or until the restriction is resolved Retest

12 ADDUCTION SOMATIC DYSFUNCTION Diagnose First, test each side for relative abduction restriction Use one hand to abduct the restricted leg to the barrier Physician provides counterforce and supports the patient s knee Physician uses caudad hand for fine tuning. Treat Physician uses cephalad hand to stabilize the opposite leg (or pelvis) Patient makes their muscle effort by attempting to adduct the lower extremity toward midline (matching the physician s force) for 3-5 seconds After the patient relaxes for a short time: Physician abducts the leg to the new feather edge of the restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

13 Diagnose Test each side for adduction restriction, lifting the LE enough to clear the opposite side The physician adducts the patient s leg to the feather edge of the restrictive barrier The physician uses his other hand to stabilize the pelvis (ASIS) on the side of the restriction, to prevent the pelvis from rotating ABDUCTION SOMATIC DYSFUNCTION Treat The patient is asked to abduct their leg away from midline, matching the physician s counterforce for 3-5 seconds After the patient relaxes for a short time: Physician adducts the leg to the new feather edge of the restrictive barrier Cycle is repeated 2-4 times or until the restriction is resolved Retest

14 HIP Posterior Pelvis Counterstrain Piriformis Posterior Lateral Trochanter (PLT) Lateral Trochanter (LT)

15 Dx: Piriformis (PIR) Tenderpoint About half to two thirds of the way from the ILA (inferolateral angle of the sacrum) to the greater trochanter Push toward or away from the musculotendinous junction of the piriformis muscle (either direction will stretch the nociceptors and cause them to fire) Piriformis

16 Tx: Piriformis (PIR) Counterstrain Marked flexion of the hip and abduction Fine tune with external or internal rotation Leg is off the table (prone) or ankle is resting on your knee (supine) and flexed up to 135º Hip is abducted External rotation of the thigh Prone - The peeing dog position

17 Dx & Tx: Posterior Lateral Trochanter (PLT) Superolateral aspect of the posterior surface of the greater trochanter Probably the lateral aspect of the piriformis muscle (PLT) Extension Marked external rotation Abduction if needed for fine tuning

18 Dx & Tx: Lateral Trochanter (LT) Along the iliotibial band distal to the greater trochanter TFL Patient prone Moderate abduction of the thigh off the table Slight flexion (LT) Greater Trochanter (LT) Iliotibial Band

19 Posterior Pelvis Counterstrain Tenderpoint Location Treatment Position Piriformis Midpoint between the ILA and the greater trochanter Marked flexion of the hip Abduction Fine tune with external or internal rotation PLT Posterior lateral trochanter Extension Marked external rotation Possibly slight abduction Lateral trochanter Along the iliotibial band distal to the greater trochanter Moderate abduction of the thigh Slight flexion

20 Combined Myofascial Release / Muscle Energy Unwinding of Hip Patient supine with physician standing adjacent to the dysfunctional hip, facing the patient s head Flex patient s hip and knee, slide your hand furthest from the patient under their pelvis so as to monitor the sacroiliac (SI) joint with your finger pads Hold the flexed knee with your hand closest to the patient or stabilize it against your chest/upper abdomen Use the knee as a long lever to mobilize the femur, slowly in a circular manner, evaluating the full range of motion of the hip and treating with MFR Pause at any region that feels restricted Have the patient push against your hand or body, in a perpendicular direction from the circle, to loosen the area of restriction with ME Continue to mobilize and treat the hip, with the previous three steps, until there is an increased range of motion in the hip If the patient expresses pain when the femur is flexed and adducted, check the psoas muscle at the inguinal ligament. If it is tender or painful, treat it with either Counterstrain or a Muscle Energy stretch and then return to the hip unwinding. Oblique view of Psoas attachment on the lesser trochanter

21 Lymphatic Drainage

22 Popliteal Fossa Direct MFR and Lymphatic Drainage (Supine Traction Hamstring Spread) Palpate the tissues in the popliteal fossae to see if they feel congested or tight. Sit or stand by the supine patient on the side to be treated. Place your fingers in the popliteal fossa and exert traction, pulling the hamstring tendons gently laterally. Allow the foot to hang freely while you support the leg, adjusting the traction to keep the patient comfortable. Hold for 15 to 60 seconds or until the tissue relaxes The patient feels progressive warmth in the thigh, leg, and foot. Retest Posterior view - Hand placement

23 Lower Extremity Petrissage Face the supine patient s head, sitting on the side to be treated Place the patient s leg over your shoulder, leg, or pillows to stabilize and augment the treatment (leg higher than the heart). UPPER LEG Place your hands around the upper thigh, close to the hip Using light pressure from the hands, twist the superficial tissue gently in the same direction (counterclockwise or clockwise), starting proximally and proceeding distally toward the foot. Pause for several seconds as you apply this stretch to the tissues. Move down a hand s length distance each time. This can be repeated up to three to four times until adequate drainage is achieved. LOWER LEG Circle the lower leg with your fingers, with your fingers or thumbs in the middle of the calf muscles Squeeze the calf muscles gently, progressing distally to the ankle. You may also rock your body forward and backward slightly to create flexion and extension of the knee and hip.

24 Posteriorly Subluxed Meniscus Technique: Supine direct ligamentous articular release Symptoms/Diagnosis: Pain in the knee, quite often anterior and inferior to the patella and either lateral or medial. There may be pain deep in the middle of the knee accompanied by a popping or clicking sensation. There may also be a Baker s cyst present. The patient is supine with the legs straight and relaxed. The physician stands or sits at the side of the table inferior to the patient s knee, facing the head of the table. Once all strains in the popliteal fossa have been released (direct myofascial pressure works well in this space), palpate the back of the knee for any firm or tender lumps (looking for a posteriorly subluxed meniscus). If either condition or a combination of both conditions is encountered, use the tip of the pad of the finger of one hand reinforced with the tip of the finger from the other hand to put direct, steady pressure on the posterior aspect of the meniscus until it slips back into its normal position and the lump disappears.

25 Balanced Ligamentous Tension: The Million Dollar Knee Technique Compliments of Anne Wales, D.O.

26 TIBIOFEMORAL MOTION Knee Flexion The larger articular surface of the medial joint surface allows for internal rotation of the tibia on the femur during flexion Associated with short leg Knee Extension The larger articular surface of the medial joint surface allows for external rotation of the tibia on the femur during extension Associated with long leg

27 Diagnosis of Tibial Rotation with Patient Seated The physician should make sure hip, fibular and ankle function is normalized to give greater efficacy and duration to the technique; otherwise, dysfunctions in these areas may interfere with accurate diagnosis and treatment. The patient is seated with knees slightly past the edge of the table so that the tibias may move freely. The physician gently grasps the tibia with both hands from an anterior approach position. The patient rotates their trunk to one side. The tibia should follow the turning of the shoulders based on the myofascial relationships of the lower leg with the thorax and pelvis. For example, turning the trunk right turns both tibias to the right; this is a subtle motion, but with practice becomes much more obvious. The patient then returns to neutral. The patient then turns their trunk in the opposite direction. Whichever direction the tibia doesn t turn as far is the direction of limited motion.

28 Internally Rotated Tibia - The Gist: Same Shoulder + Plantarflex + Inhale While performing the following maneuvers, the physician is gently grasping and following the motion of the tibia. The patient turns their torso toward the side of the affected tibia, which brings the tibia into external rotation. As the tibia externally rotates, the physician follows it. The patient then plantarflexes the foot of the symptomatic knee and inhales deeply; this brings the patient s tibia into even greater external rotation. The physician should hold the tibia in this position. Once these three maneuvers are accomplished and the tibia has gone as far as it can, the physician should firmly hold the tibia to prevent its return towards the center as you ask the patient to turn back to the center, and release their breath and relax their foot. This holds the tibia in external rotation. It is very important for the physician to remain patient as this release may take a few minutes. As release of the myofascial, ligamentous and articular components occurs, there will initially be a subtle, but increasingly obvious release of the tibia into external rotation. This often occurs in stages and ultimately will end at the physiologic barrier with the sensation of the knee joint decompressing and the tibia gently dropping towards the floor. The physician should then gently allow the tibia to return to neutral and reassess the ROM.

29 Externally Rotated Tibia - The Gist: Opposite Shoulder + Dorsiflex + Exhale While performing the following maneuvers, the physician is gently grasping and following the motion of the tibia. The patient turns their torso toward the side opposite of the affected tibia, which brings the tibia into internal rotation. As the tibia internally rotates, the physician follows it. The patient then dorsiflexes the foot of the symptomatic knee and exhales deeply; this brings the patient s tibia into even greater internal rotation. The physician should hold the tibia in this position. Once these three maneuvers are accomplished and the tibia has gone as far as it can, the physician should firmly hold the tibia to prevent its return towards the center as you ask the patient to turn back to the center, and release their breath and relax their foot. This holds the tibia in internal rotation. It is very important for the physician to remain patient as this release may take a few minutes. As release of the myofascial, ligamentous and articular components occurs, there will initially be a subtle, but increasingly obvious release of the tibia into internal rotation. This often occurs in stages and ultimately will end at the physiologic barrier with the sensation of the knee joint decompressing and the tibia gently dropping towards the floor. The physician should then gently allow the tibia to return to neutral and reassess the ROM.

30 HVLA Fibular Head

31 Fibular Head Physiologic Motion The proximal fibular head moves in anterolateral and posteromedial directions, relative to the proximal tibia Reciprocal Motions When the proximal fibular head moves posteriorly, the distal fibula moves anteriorly (and vice versa). Related Motion External rotation of the tibia causes the proximal fibular head to move anteriorly (and the distal fibula, posteriorly). Somatic Dysfunction Dx Anterior fibular head Fibular head prefers anterior movement/position Fibular head has restricted posterior movement Posterior fibular head Fibular head prefers posterior movement/position Fibular head has restricted anterior movement Reciprocal motions. External rotation of the tibia (C) moves the distal fibula posteriorly (B) and reciprocally is associated with the fibular head moving anteriorly (B1). The opposite is true (A, A1) with internal rotation (D) of the lower leg. (Illustration by W.A. Kuchera.) FOM 3 rd edition Fig

32 Fibular Head Diagnosis Hold the leg in place with one hand around it, and your thumb in front of the tibia (not shown). Grip the fibular head between your thumb and index finger. Push posteromedially and pull anterolaterally along the glide path to test motion. Anterolateral glide An anterior fibular head resists posteromedial motion. Posteromedial glide A posterior fibular head resists anterolateral motion. You may perform the test with the patient seated or supine. If supine, the knee should be flexed 15.

33 Posterior Fibular Head HVLA 1. Flex the hip and knee. 2. Place the proximal phalanx of your index finger (or MTP joint) behind the fibular head as a wedge. 3. Start externally rotating the tibia through the ankle (reciprocal motion moves the fibular head anteriorly as cylindrical rotation compresses the fibular head against your wedge). 4. At the same time, increase knee flexion to take out the tissue slack, applying slight lateral traction with the hand behind the fibular head. 5. When you reach the barrier, direct a short lever thrust by flexing the knee further (long lever).

34 Peroneal Neuropathy Damage to the peroneal nerve that causes some sensory loss, but primarily muscle weakness of the muscles that dorsi flex the foot. The patients usually have a foot drop and what is termed steppage gait. These neuropathies can be induced by trauma. The peroneal nerve runs around the posterior portion of the fibular head before diving deep into the leg.

35 Counterstrain - Knee

36 Anterior Cruciate Ligament ANTERIOR VIEW POSTERIOR VIEW

37 ANTERIOR CRUCIATE LIGAMENT (ACL) ACL PCL Fibular Head Kitokophotography 2016 Eva Shay DO Tenderpoint Locations: In the hamstring muscle tendons at the level of the widest part of the popliteal space (medially and laterally) (L. Jones preferred)

38 Patient supine Stand on the side of the tenderpoint Place a rolled up towel under the distal femur Slowly, gently push the tibia posteriorly to shorten the ACL at times up to forty pounds of force may be needed Monitors the tenderpoint for tissue texture changes Re-check tenderness after 30 seconds Hold for a minimum of 90 seconds Slowly take the patient out of the treatment position Retest ACL

39 Posterior Cruciate Ligament ANTERIOR VIEW POSTERIOR VIEW

40 POSTERIOR CRUCIATE LIGAMENT (PCL) Tenderpoint Location: Close to the middle of the popliteal space (L. Jones preferred)

41 Patient lies supine Physician stands on the side of the tenderpoint A rolled up towel is placed under the proximal tibia The femur is pushed posteriorly Shortens PCL Requires some force Force is applied slowly and gently Physician monitors the tenderpoint for tissue texture changes during treatment Physician re-checks tenderness every 30 seconds Hold for a minimum of 90 seconds Slowly take patient out of treatment position Recheck tenderpoint PCL

42 MEDIAL MENISCUS / MEDIAL COLLATERAL LIGAMENT

43 MEDIAL MENISCUS / MEDIAL COLLATERAL LIGAMENT Medial Hamstring Tenderpoint Location: Antero-medial aspect of the meniscus on the joint line

44 MEDIAL MENISCUS / MEDIAL COLLATERAL LIGAMENT Flexion/Adduction/internal rotation Patient lies supine Physician sits on the side of the tenderpoint Patient hangs the leg off of the table Knee is flexed to about 60 Applied force is mostly internal rotation of the tibia Slight adduction of the tibia (varus) Physician monitors the tenderpoint for tissue texture changes during treatment Physician re-checks tenderness every 30 seconds Hold for a minimum of 90 seconds Slowly take patient out of treatment position Recheck tenderpoint ** Caution is emphasized against too much adduction secondary to the long lever of the leg

45 MEDIAL HAMSTRING (SEMIMEMBRANOSIS) 2 Medial Hamstring / Semimembranosus counterstrain tenderpoints Left leg Right leg Tenderpoint Location: Left leg 1. Either in front of or behind the attachment of the medial hamstring (L. Jones preferred) 2. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur

46 MEDIAL HAMSTRING Flexion/Internal Rotation of lower leg/adduct leg Patient lies supine or prone Physician stands on the side of the tenderpoint Hip and knee flexed to about 90 Leg/Knee is adducted Internally rotated lower leg Almost all force with rotation Plantar flexion of the ankle Physician monitors the tenderpoint for tissue texture changes during treatment Physician re-checks tenderness every 30 seconds Hold for a minimum of 90 seconds Slowly take patient out of treatment position Recheck tenderpoint Physician may ABduct the opposite leg so as to facilitate the Adduction.

47 LATERAL MENISCUS / LATERAL COLLATERAL LIGAMENT

48 LATERAL MENISCUS / LATERAL COLLATERAL LIGAMENT Patellar Tenderpoints Lateral Collateral Ligament Lateral Meniscus Medial Meniscus Lateral Meniscus Patellar Tendon Patellar Tendon Tibial Tuberosity Lateral Hamstring Knee Extender Tenderpoints Tenderpoint Location: Lateral aspect of the meniscus on the joint line

49 LATERAL MENISCUS/LATERAL COLLATERAL LIGAMENT Flexion/Slight abduction/+/- Internal or External rotation This treatment is variable Patient lies supine Physician sits on the side of the tenderpoint Patient hangs the leg off of the table Knee is flexed to about Slight abduction of tibia May require mild internal or external rotation) of the tibia Physician monitors the tenderpoint for tissue texture changes during treatment Physician re-checks tenderness every 30 seconds Hold for a minimum of 90 seconds Slowly take patient out of treatment position Recheck tenderpoint

50 Lateral Hamstring (Biceps femoris) Tenderpoint Location: 1. Lateral aspect of the meniscus on the joint line (L. Jones preferred) 2. In the posterior thigh lateral to the midline approximately halfway down the shaft of the femur Lateral Hamstring / Long Head Biceps Femoris counterstrain tenderpoints 2 1

51 LATERAL HAMSTRING Flexion/External rotation of lower leg/abduction of upper & lower leg Patient lies supine or prone Physician sits stands on the side of the tenderpoint Knee flexed to about 90 Leg/Knee slight abducted Externally rotated lower leg Almost all force with rotation Plantar flexion of the ankle Physician monitors the tenderpoint for tissue texture changes during treatment Physician re-checks tenderness every 30 seconds Hold for a minimum of 90 seconds Slowly take patient out of treatment position Recheck tenderpoint

52 KNEE EXTENDERS 3 Tenderpoints for the Knee Extenders Over the front (anterior) of the medial meniscus On the patellar tendon On the front medial surface of the tibia Patient complains of pain with hyperflexion (i.e. squat)

53 1. ANTERIOR ASPECT OF MEDIAL MENISCUS Hyperextension ± Internal Rotation 2. PATELLAR TENDON Hyperextension ± Internal Rotation 3. REGION OF TIBIAL TUBEROSITY Hyperextension ± External Rotation

54 PATELLA Patient complains of pain usually felt 1.5 above the patella Tenderpoints are found along the perimeter of the patella Treatment is pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint

55 Knee Counterstrain Tenderpoint Location Treatment Anterior Cruciate Ligament (ACL) In the hamstring muscle tendons at the level of the widest part of the popliteal space (medially and laterally) Place a rolled up towel under the distal femur Slowly, gently push the tibia posteriorly to shorten the ACL Posterior Cruciate Ligament (PCL) Close to the middle of the popliteal space A rolled up towel is placed under the proximal tibia The femur is pushed posteriorly & shortens PCL Requires some force Force is applied slowly and gently Medial meniscus/ Medial collateral ligament Antero-medial aspect of the meniscus on the joint line Patient hangs the leg off of the table Knee is flexed to about 60 Applied force is mostly internal rotation of the tibia Slight adduction of the tibia (varus) Medial hamstring (Semimembranosis) 1. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur 2. Either in front of or behind the attachment of the medial hamstring Hip and knee flexed to about 90 Leg/Knee is adducted Internally rotated lower leg Plantar flexion of the ankle by compression on the calcaneus

56 Knee Counterstrain Tenderpoint Location Treatment Lateral meniscus/ Lateral collateral ligament Lateral hamstring (Biceps femoris) Knee extenders Lateral aspect of the meniscus on the joint line 1. In the posterior thigh lateral to the midline approximately halfway down the shaft of the femur 2. Lateral aspect of the meniscus on the joint line 3 Tenderpoints for the Knee Extenders 1. Over the front (anterior) of the medial meniscus 2. On the patellar tendon 3. On the front medial surface of the tibia This treatment is variable: Patient hangs the leg off of the table, Knee is flexed to about Slight abduction of tibia May require mild internal or external rotation) of the tibia Knee flexed to about 90 Leg/Knee slight abducted Externally rotated lower leg Almost all force with rotation Plantar flexion of the ankle by compression on the calcaneus 1 & 2 Hyperextension and ± Internal Rotation 3. Hyperextension and ± External Rotation Patella Found along the perimeter of the patella Pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint

57 Knee Counterstrain Tenderpoint Location Treatment Anterior Cruciate Ligament (ACL) Posterior Cruciate Ligament (PCL) Medial meniscus/ Medial collateral ligament Medial hamstring (Semi-membranosis) Lateral meniscus/ Lateral collateral ligament Lateral hamstring (Long Head-Biceps femoris) Knee extenders In the hamstring muscle tendons at the level of the widest part of the popliteal space (medially and laterally) Close to the middle of the popliteal space Antero-medial aspect of the meniscus on the joint line 1. In the posterior thigh medial to the midline approximately halfway down the shaft of the femur 2. Either in front of or behind the attachment of the medial hamstring Lateral aspect of the meniscus on the joint line 1. In the posterior thigh lateral to the midline approximately halfway down the shaft of the femur 2. Lateral aspect of the meniscus on the joint line 3 Tenderpoints for the Knee Extenders 1. Over the front (anterior) of the medial meniscus 2. On the patellar tendon 3. On the front medial surface of the tibia Place a rolled up towel under the distal femur Slowly, gently push the tibia posteriorly to shorten the ACL A rolled up towel is placed under the proximal tibia The femur is pushed posteriorly which shortens PCL, Requires some force, Force is applied slowly and gently Patient hangs the leg off of the table, Knee is flexed to about 60 Applied force is mostly internal rotation of the tibia, Slight adduction of the tibia (varus) Hip and knee flexed to about 90 Leg/Knee is adducted, Internally rotated lower leg, Plantar flexion of the ankle by compression on the calcaneus This treatment is variable: Patient hangs the leg off of the table, Knee is flexed to about 35-40, Slight abduction of tibia, May require mild internal or external rotation) of the tibia Knee flexed to about 90, Leg/Knee slight abducted, Externally rotated lower leg, Almost all force with rotation Plantar flexion of the ankle by compression on the calcaneus 1 & 2 Hyperextension and ± Internal Rotation 3. Hyperextension and ± External Rotation Patella Found along the perimeter of the patella Pressure (only a few ounces) over the part of the perimeter of the patella that is opposite of the tenderpoint